Sample State form for EAB (Michigan Parent Information Worksheet)

PARENT INFORMATION WORKSHEET
Michigan Department of Health and Human Services
Division for Vital Records and Health Statistics

The information you provide below will be used to create your child’s birth certificate. The birth certificate is a document
that will be used for legal purposes to prove your child’s age, citizenship and parentage. This document will be used by
your child throughout his/her life. Michigan law provides protection against the unauthorized release of identifying
information from the birth certificate to ensure the confidentiality of the parents and their child.

Note that a certificate of birth must be filled out completely. Incomplete certificates are not accepted for filing. The
information will be used to prepare your child’s birth certificate which is a legal document. The law requires that the
information be supplied. It is also very important that the information provided is truthful. Providing false information
is against the law.
Full Name of Child:_____________________________________________________________________________

(First)

(Middle)

(Last)

(Suffix)

Mother's Current
Legal Name:_____________________________________________________________________________

(First)

(Middle)

(Last)

Mother's Name Before
First Married:_____________________________________________________________________________

(First)

(Middle)

(Last)

State of Birth (If not
Date of

Social
USA, name country):_______________________ Birth:___________________Security #:____________________
Residence (Check one
box and specify):

Inside city or village of _______________________

Twp. of ___________________

County: ______________________ State: _________ Zip Code:

The law specifically stipulates the process for naming a second parent on a child's certificate of birth. The birth
certificate for a child must record the mother's spouse as the second parent whenever the mother was married at the
time the child was conceived. If the mother was not married at the time of conception, but was married at the time of
birth, the individual named as the second parent must be the spouse at the time of birth. If the mother was not
married at either time, the second parent may only be named if the mother and father complete an affidavit of parentage
or present a court order stipulating who should be recorded as the second parent.
Was mother married at birth or conception? If mother’s divorced -
Yes
No date finalized: ____/____/____

State where
divorce is filed: _____________

Spouse/Father’s
Legal Name: ________________________________________________________________________________

(First)

(Middle)

(Last)

(Suffix)

State of Birth (If not

Date of

Social
USA, name country):____________________________ Birth:__________________ Security #:_____________________
Additional information
that will be kept
confidential:

Race: American Indian, Black,
White, etc. If Asian, give nationality,
i.e. Chinese, Filipino, etc. (Enter all
that apply.)

Ancestry: Mexican, Cuban, Arab,
English, French, etc. If American Indian,
enter principal tribe. (Enter all that apply.)

Hispanic
Origin?

(Yes or No)

Mother:_______________________________ ___________________________________

______

Spouse/Father:_______________________________ ___________________________________

______

Mother’s Mailing Address:______________________________________________________________________________________________________________________________________

(Number & Street)

(City)

(State)

(Zip)

Spouse/Father’s Mailing Address
(If different than Mother’s):_____________________________________________________________________________________________________________________________________

DCH-0486A (Rev. 3-17)

(Number & Street)

AUTHORITY: ACT 368, PA 1978

1

(City)

(State)

(Zip)

Education: Indicate the category that best describes the highest degree or level of school
completed by the mother and the spouse/father:

1. 8th grade or less

2. 9th-12th grade; no diploma
3. High school graduate or GED

Mother ____
4. Some college but no degree

5. Associate degree (AA,AS)

6. Bachelor’s degree (BA,AB,BS)

7. Master’s degree
8. Doctorate/ professional degree
9. Unknown

Spouse/Father ____
(MA,MS,MEng,MEd, MSW, MBA)
(PhD,EdD,MD,DO,DDS,DVM,LLB,JD)

Yes

Did mother receive WIC food while pregnant?
Was this intended to be a home birth?

Yes

No

If yes, where was the birth planned? ______ 1. Home

No

Unknown
Unknown

2. Birthing Center
3. Physician’s Office
5. Other (specify)_________________

4. Unknown

Who would have attended the birth? ______ 1. Midwife

2. Certified Nurse Midwife
3. Physician
4. Partner
5. Family/friend
6. Self
7. Other (specify)_____________________ 8. Unknown

Mother's Pre-pregnancy Weight _________ lbs.
Mother Smoked Before or During

Pregnancy?
Yes

No

Unknown

Mother’s Height _______ ft. ______ in.

Did Mother Quit Smoking?
Yes
No
Unknown

Do Others in the
Household Smoke?

Date
She Quit:_____________

Yes

No

Unknown

For each time period, enter either the number of cigarettes or the number of packs of cigarettes smoked.
Average number of cigarettes or packs of cigarettes smoked per day.

# of cigarettes
# of packs

Three months before pregnancy

_____

or

_____

First three months of pregnancy

_____

or

_____

Second three months of pregnancy

_____

or

_____

Third trimester of pregnancy

_____

or

_____

Do you want a Social Security Number issued for your baby?

Yes

No

I request that the Social Security Administration assign a Social Security Number to the child named on this form and
authorize the State to provide the Social Security Administration with the information from this form which is needed
to assign a number.

Signature of informant: ____________________________________________ Date: ___________________

If other than the mother, what is the name of the person providing information for this worksheet?

_________________________________________________________

(First)

(Middle)

(Last)

_______________
Relationship to mother

(Completion of this form is voluntary)
The Michigan Department of Health and Human Services (MDHHS) does not discriminate against any individual or group because of race,
religion, age, national origin, color, height, weight, marital status, genetic information, sex, sexual orientation, gender identity or expression,
political beliefs or disability.
DCH-0486A (Rev. 3-17)

AUTHORITY: Act 368, PA 1978