Section 5-C:19 - Completion of Birth Worksheet for Hospital or Institutional BirthsI. A hospital, institution, birthing center, attendant, or parent shall file with the division a birth record for each live birth which occurs in the state of New Hampshire.II. In the case of a hospital or institution live birth, a completed birth worksheet shall include the following, provided by personnel as indicated: (a) The hospital or institution birth registrar or designee shall provide: (1) Information regarding the child, including name, date and time of birth, and sex.(2) Information regarding the facility, including name, street address, city or town, and county.(3) Information regarding the mother including: (A) Current name and maiden name.(B) Date of birth and birthplace.(C) City or town, county, and state of residence.(D) Residential address and complete mailing address if different from the residential address, or, if the same as the residential address, her zip code only.(E) Social security number.(F) Usual occupation and the business or industry in which employed.(I) Whether she was married at the time of the birth of child, or conception of child, or any time between.(4) Information regarding the father including: (B) Date of birth and birthplace.(C) City or town, county, and state of residence.(D) Residential address and complete mailing address if different from the residential address, or, if the same as the residential address, his zip code only.(E) Social security number.(F) Usual occupation and the business or industry in which employed.(5) The method of payment for prenatal care and for delivery.(6) Statistical information from the mother, medical reports, and her physician regarding the mother and child including: (A) Number of live births, not including this child, now living and now dead.(B) Date of the last live birth.(C) Other terminations of pregnancy, any time after conception.(D) Date of the last other termination of pregnancy.(E) Date last normal menses began.(F) Month that prenatal care began.(G) Total number of prenatal visits.(H) Birth weight of the child.(I) Clinical estimation of gestation in weeks.(J) Plurality of the child, including but not limited to single, twin, or triplet.(K) Birth order of the child.(L) The Apgar score, which is an evaluation of a newborn infant's physical status, at one minute and at 5 minutes.(7) If the mother is transferred to another facility before or after giving birth, transfer information for the mother and child including: (A) Whether the mother was transferred prior to delivery or after delivery.(B) Whether the infant was transferred after delivery.(C) Whether the child was living or dead at the time of the report.(8) Information regarding the medical aspects of the pregnancy including: (A) Any medical risk factors for the pregnancy.(B) Any other risk factors for the pregnancy.(C) Any obstetric procedures performed during the course of the pregnancy.(D) Any complications of labor and delivery.(E) The method of delivery.(F) Any abnormal conditions of the newborn.(G) Any congenital anomalies of the child.(9) Indication from one parent whether the division shall be authorized to provide the Social Security Administration with data from the birth record in order for the Social Security Administration to issue a social security number.(10) Indication from one parent whether the division shall be authorized to release birth record information to the New Hampshire immunization registry.(11) Signature of the individual who interviewed the parent or other informant certifying that the information has been recorded exactly as given by the parent or other informant or has been taken from medical records.(b) A parent or other informant shall provide his or her signature certifying that the information supplied is a true and correct representation of the facts to the best of his or her knowledge; the date signed; and the informant's relationship to the child.III. A physician member of the institution's obstetrics team or service, the chief of obstetrics, the chief of the medical staff or the hospital administrator shall, within 72 hours of the birth, certify that the child was born alive at the place and time and the date stated by providing: (a) His or her signature as certifier.(c) His or her name and title.(d) The name and title of the attendant if other than the certifier.(e) The attendant's mailing address.IV. The birth worksheet shall not be signed by a parent or informant until the child has been given a name or the mother is being discharged from the hospital, whichever is sooner. V. When both a physician and a nurse midwife are present at a hospital birth, the physician shall sign the birth worksheet and be named as the certifier, and the name of the nurse midwife shall be entered as the attendant at birth.VI. When a physician is not present and a nurse midwife is present at a hospital birth, the nurse midwife shall sign the birth worksheet and be named as the certifier.VII. Any item of information not obtainable shall be indicated as: "not known" when the information is not known; "not available" when the information is known but not immediately available; or "refused to provide" when the parent or informant refuses to provide the information.VIII. In the case of an unwed mother, unless an affidavit of paternity has been executed, the notation "not stated" shall be entered in the spaces provided for information concerning the father.IX. When a child is born in a moving conveyance, the city or town of birth shall be that city or town where the child was first removed from said conveyance.X. When a married mother refuses to give information concerning her husband as father of the child, the hospital shall enter "not stated" on the birth record for all information pertaining to the father of the child.XI. For a birth which occurred in a hospital or institution, the hospital or institution birth registrar or designee shall initially record information for the birth record on the birth worksheet and permanently retain the birth worksheet in the mother's medical record files at the hospital. 2005, 268:1, eff. Jan. 1, 2006.