Mothers worksheet

Vital Statistics Services
Vital Statistics Services 1

Quick Information
 ALL facility births are to be filed electronically.
 Birth certificates must be filed with the local
registrar within 10 days from the date of birth.
 The medical certifier/attendant must certify to
the birth within 7 days after the date of birth.
 If the attendant has not signed the certificate
within seven (7) days of the date of the birth,
the person in charge of the institution or a
designated representative shall complete and
sign the certificate.

Checklist for Filing a Birth
Certificate (Mother’s Worksheet)
PLEASE MAKE SURE:
 The worksheet has an accurate description in English for each field
 The worksheet is completely filled out, readable and accurate
 If there is missing information please make sure to obtain it before filing the
record
 Dates should follow the format: month/day/year
 Mom signed the worksheet, verifying the information was accurate
 If the mother didn’t sign the informant (person providing the information) has
provided the information to the best of their knowledge and is an adult

Filing a Birth Certificate

Getting Logged In
 Go to https://vss.health.wyo.gov
 Log in with the userID and password
provided by Vital Statistics Services.
 If you forgot the password or userID
please contact Vital Statistics Services
at wdh-vitalstatisticsservices@wyo.gov.

Confidentiality
 When logging in for the first time and
every quarter you will have to agree to a
user confidentiality agreement.
Do not share your password with any
other user!
 If you don’t agree to the terms, you will
not be allowed to use the system.

Part II

Worksheets
 All items on the mother’s worksheet
must be completed and the document
must be signed.
 If there are ANY blanks OR conflicting
information, those items must be
completed or verified.
 The mother’s worksheet SHOULD NOT
BE ACCEPTED IF ANY ITEM IS NOT
COMPLETE.

Create the Birth Record
 Choose the “New Record” link from the grey
toolbar.
 Enter the full name of the child.
 Enter the date of birth.
 The Birth Facility defaults based on your
facility.
 Choose the medical certifier.
In some cases this will be a dropdown menu with
different facilities. Choose the facility in which the
certifier is associate with.
 Registration county
Defaults based your facility. It can not be changed.

New Record
1. Once all pieces have been entered, choose
“Create”.
2. The system will run a check to make sure this is
not a duplicate record.
3. If the system doesn’t find a duplicate record, you
will see the “Birth Mother’s Information” page.

Birth Mother’s Information
 Once the record is created you will be
taken to the mother’s information page.
 You will notice that this page is broken
up into four different sections:
Child
Mother
Father
Information

Child Section
 The child’s name, date of birth, and the
facility are already filled in based on the
information entered to create the record.
 If the child has a suffix, you will still have
to enter that information using the drop
down list.
 Enter the time of birth using military
time.

Child Section
When entering the time of birth be sure to enter
the time using Military time.

Military Time

Mother Section
• Enter the mother’s full current legal name.
○ The information entered into the first and middle name
fields of her current name will auto-fill those same fields in
the mother’s name prior to first marriage.
• Enter the mother’s date of birth.
 Enter the mother’s name prior to first marriage.
 You will be required to enter the mother’s maiden name, her
last name prior to marriage.
 Enter the mother’s birthplace.
 You must choose a country first and then choose a state.
 Enter the mother’s residence and whether or not
the residence is inside city limits.

Mother’s Information
The information entered into the first
and middle names of the mother’s
Legal name will auto-fill those same
fields in the mother’s name Prior to
first Marriage.
When entering the
mother’s residence be
sure to enter the address
in the first line. The only
information that should be
in Line 2 is an apartment,
lot, or space number.
If there is no PHYSICAL address, only a PO box,
you MUST enter “Unknown” for the residence
address information. You MUST still enter the rest
of the information.
Only put the PO box information in the mailing
address

Father’s Information
 Enter the full name of the father.
The only name that can be listed here is the
natural father of the child.
 Enter the father’s date of birth.
 Enter the father’s birthplace.
You must choose a country before you can
pick a state.
 When a father is named on the
record, these fields are required.

Father’s Information
If the father is to be named on the
record, this information is
REQUIRED. If a father will not be
named, you can skip this section.

Other Information
 Enter the mother’s mailing address.
You are allowed to enter PO box number for this
field. However, you are still required to enter the city
and zip code information as well.
 Choose the mother’s marital status. This
information must be entered exactly as it is
shown on the mother’s worksheet.
When Vital Statistics Services has questions about
the marital status we will go back and review the
worksheet completed by the mother.
If there are questions about this section, call VSS for
additional information
 Choose whether or not a Paternity/Denial
Affidavit has been completed.

Other Information
When entering the mailing
address, be sure that ALL
fields are complete.

Mother’s Marital Status
 If the mother was married at the time of
conception, birth, or anytime in between
and her husband is the father:
Wyoming statute 35-1-411 “Name of father
on birth certificate”, The husband’s name
shall be entered on the Birth Certificate as
the father.
You may run into situations in which the
mother refuses to name or provide
information about the father, please call VSS
when this happens.

Naming the Father
 Please use the following chart to help determine
if a father can be named on the birth record:
Is Mother
Married?
Is Husband the
Father?
Paternity
Acknowledgement
Signed and
Notarized
Denial Affidavit
Signed and
Notarized?
Can Father’s
Name be on
the Record?
YES YES N/A N/A YES
(Required by
Law)
YES NO YES YES YES
YES NO NO YES NO
YES NO NO NO CONTACT
VSS OFFICE
YES NO YES NO NO
NO N/A YES N/A YES
NO N/A NO N/A NO

Other Information Continued
 Information Released to obtain:
Social Security Number?
○ If the mother chooses “YES”, Vital Statistics Services
will send the information automatically to the SSA and
the mother will receive the card via mail within 3-6
weeks.
Enroll child in immunization registry?
○ The immunization registry is a computerized
information system used to collect vaccination
information to help assure that immunizations are given
to protect individuals, especially children, from vaccine-
preventable diseases.
○ All information is strictly confidential and may only be
accessed by licensed physicians and public health
authorities for the appropriate and timely vaccination of
the child.

Parent’s Social Security Numbers
 Furnishing the parent’s Social Security
Numbers is required by Federal Law, 42
USC 405(c) (section 205(c)).
The numbers will be made available to the
Wyoming Department of Family Services to
assist with child support enforcement activities
and to the IRS for the purpose of determining
Earned Income Tax Credit compliance.
 If either parent does not have a SSN you
must enter 999-99-9999.
If a father is not named, no SSN information is
required.

Other Information and Parent’s
SSN
Furnishing the
parent’s Social
Security Numbers
is required by
Federal Law, 42
USC 405(c)
(section 205(c)).
If either parent does not have a SSN you
must enter 999-99-9999.
If a father is not named, no SSN
information is required.

Education Level
 Choose the box that indicates the highest
education level completed by the mother.
 If she is currently enrolled, check the box
that indicates the previous grade or highest
degree received. Do not leave this item
blank.
 Education is highly related to fertility, health
practices, and pregnancy outcome. It is
also used as an indicator of socioeconomic
status.

Hispanic Origin
 The Hispanic origin and Race questions should be asked
independently.
 ‘‘Hispanic’’ is not a race, and a mother/father who is of
Hispanic origin may be of any race.
 Do not leave this item blank. ‘‘Hispanic’’ is a self-
designated classification for people whose origins are
from Spain, the Spanish-speaking countries of Central or
South America, the Caribbean, or those identifying
themselves generally as Spanish or Spanish-American.
 Origin can be viewed as ancestry, nationality, or country
of birth of the person or person’s parents or ancestors
prior to their arrival in the United States.
 Although the prompts include the major Hispanic groups,
other groups may be specified under ‘‘Yes, other
Spanish/Hispanic/Latino(a).’’

Hispanic Origin Continued
 Check the box that best describe
whether the mother/father is
Spanish/Hispanic/ Latino(a).
If the mother/father indicates an ethnic origin
not on the list, enter it in the ‘‘Specify’’
space.
 If the mother/father is not of Hispanic
origin, check the box indicating ‘‘No, not
Spanish/Hispanic/Latino(a).”

Race
 The Race and Hispanic origin questions should be
answered independently. Do not leave item blank. If
there is no checkbox for the response, check the box
‘‘Other (Specify)’’ and enter the response in the blank,
even if it is not a race.
 American Indian and Alaska Native refer only to those
native to North and South America (including Central
America) and do not include Asian Indian. Please specify
the name of enrolled or principal tribe (e.g., Navajo or
Cheyenne) for the American Indian or Alaska Native.
 For Asians and Pacific Islanders, enter the national origin
of the mother. For Asians check Asian Indian, Chinese,
Filipino, Japanese, Korean, Vietnamese, or specify Other
Asian group; for Pacific Islanders check Hawaiian,
Guamanian or Chamorro, Samoan, or specify Other
Pacific Islander.

Race Continued
 In 1997, the Office of Management and Budget
mandated the use of specific guidelines in collecting
information on race and ethnicity and provided an
opportunity for individuals to choose more than one
racial category if they wish to reflect multiple racial
heritage.
 Race is essential in producing data for minority
groups and is an important variable in planning for
and evaluating the effectiveness of health programs.
 It is also used to study racial variations in
childbearing, access to health care, and pregnancy
outcomes (perinatal mortality and birth weight).

Education Level, Hispanic Origin,
and Race
‘‘Hispanic’’ is
not a race, and
a mother/father
who is of
Hispanic origin
may be of any
race.

Mother’s Height
 Enter the mother’s height in feet and
inches. If the record indicates height in
fractions such as 5 feet 6 and one-half
inches, truncate and enter 5 feet, 6 inches.
 In combination with prepregnancy weight,
mother’s height is used to calculate the
body mass index (BMI). Maternal BMI is
associated with maternal morbidity and
mortality. Maternal weight gain data are of
little value without knowledge of maternal
BMI.

Mother’s Pre Pregnancy Weight
 Record the weight in whole pounds only;
do not include fractions.
 This item collects the weight of the
mother immediately before she became
pregnant.

Did the Mother get WIC Food
during the Pregnancy
 WIC is a Special Supplemental Nutrition
Program for Women, Infants, and Children
which serves to safeguard the health of
low-income women, infants, & children up
to age 5 who are at nutritional risk by
providing nutritious supplemental foods,
health and nutrition, screening and
education, breastfeeding support, and
referrals to healthcare.
 Choose either YES or NO

Why is WIC Needed?
 Knowledge of participation in
government programs such as WIC is
helpful in judging program use and its
effect on health outcome. Participation
in programs such as WIC is also an
indicator of socioeconomic status.

Did the Mother Use Cigarettes?
 Enter the number of cigarettes the
mother smoked during an average day
during the certain time periods before
and during pregnancy.
 When entering information only enter a
value in one column (Cigarettes OR
Packs), not both.

Cigarette Use
 Smoking during pregnancy has been
determined to have an adverse affect on
pregnancy outcome.
 This information is used to evaluate the
relationship between certain lifestyle
factors and pregnancy outcome and to
determine at what levels these factors
clearly being to affect pregnancy
outcome.

Cigarette Use

Month Prenatal Care Began
 Enter the month of pregnancy when the
mother began going to the doctor for
prenatal care.
This question is asking if the mother began
prenatal care in the 1st
, 2nd
, 3rd
, 4th
, 5th
, 6th
, 7th
, 8th
,
9th
, or 10th
month of pregnancy.
Acceptable values are only between 01
and 10.
 Do not enter January, February, March,
etc…

Mother’s Height, Pre-pregnancy
Weight, WIC, and Prenatal Info.

Finished with Mother’s
Worksheet Information
 Once you have answered the tobacco
use per day you will notice that you are
done with the mother’s worksheet.
 It is very important this worksheet is
completed and signed, it provides all of
the information to establish a birth
record.
If there are any questions unanswered you
should get a response so the worksheet is
complete.

Mothers worksheet

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