VS-10B Race/Ethnicity and Education WORKSHEET (2006)



CERTIFICATES OF LIVE BIRTH AND FETAL DEATH

RACE/ETHNICITY AND EDUCATION WORKSHEET (For Reference Only)

NOTICE TO INFORMANTS:� Completion of this worksheet in conjunction with either the �Certificate of Live Birth� or the �Certificate of Fetal Death� is not required by state law.� However, the information requested is essential for determining the health problems of the population groups noted below and your cooperation is appreciated.�

FATHER�S RACE/ETHNICITY

�MOTHER�S RACE/ETHNICITY

HISPANIC, LATINO, SPANISH (check 1 box).� Enter specific origin on the certificate.

HISPANIC, LATINA, SPANISH (check 1 box).� Enter specific origin on���� the certificate.

Is the FATHER Hispanic/Latino/Spanish?

�No, not Hispanic/Latino/Spanish

�Yes, Mexican, Mexican American, Chicano

�Yes, Central American

�Yes, South American

�Yes, Cuban

�Yes, Puerto Rican

�Yes, Other Hispanic/Latino/Spanish (Specify):

��� ���____________________________________

Is the MOTHER Hispanic/Latina/Spanish?

�No, not Hispanic/Latina/Spanish

�Yes, Mexican, Mexican American, Chicana

�Yes, Central American

�Yes, South American

�Yes, Cuban

�Yes, Puerto Rican

�Yes, Other Hispanic/Latina/Spanish (Specify):

������ ____________________________________

RACE� (check 1, 2 or 3 boxes).� Enter up to 3 races on the certificate.

RACE �(check 1, 2 or 3 boxes).� Enter up to 3 races on the certificate.�

The FATHER is:

�White

�Black or African American

�American Indian or Alaska Native

����� (includes North, South, or Central

����� American Indian, Aleut or
����� Alaska Native)

����� Specify Tribe(s):______________

������ ___________________________

�Native Hawaiian

�Guamanian

�Samoan

�Other Pacific Islander (Specify):

������ _________________________

 

�Asian Indian

�Cambodian

�Chinese

�Filipino

�Hmong

�Japanese

�Korean

�Laotian

�Thai

�Vietnamese

�Other Asian (Specify):

������ ________________________

The MOTHER is:

�White

�Black or African American

�American Indian or Alaska Native
����� (includes North, South, or Central
����� American Indian, Aleut or
����� Alaska Native)

����� Specify Tribe(s):______________

������ ___________________________

�Native Hawaiian

�Guamanian

�Samoan

�Other Pacific Islander (Specify):

����� __________________________

 

�Asian Indian

�Cambodian

�Chinese

�Filipino

�Hmong

�Japanese

�Korean

�Laotian

�Thai

�Vietnamese

�Other Asian (Specify):

����� ________________________

�Other (Specify):______________________________________________

�Other (Specify):______________________________________________

�Other (Specify):______________________________________________

�Other (Specify):______________________________________________

�Other (Specify):______________________________________________

�Other (Specify):______________________________________________

�FATHER�S EDUCATION

MOTHER�S EDUCATION

Check 1 box that best describes the highest degree or level of school completed by the FATHER at the time of the delivery.� Enter education degree or level on the certificate.

Check 1 box that best describes the highest degree or level of school completed by the MOTHER at the time of the delivery.� Enter education degree or level on the certificate.

�0-11th grade.� Enter highest year completed: _____

�12th grade; no diploma.� Enter 12

�High school graduate or GED completed.� Enter HS or GED

�Some college credit, but no degree.� Enter SOCOL

�Associate degree (e.g. AA, AS).� Enter ASSOC

�Bachelor�s degree (e.g., BA AB, BS).� Enter BACH

�Master�s degree (e.g., MA, MS, MEng, MEd, MSW, MBA).� Enter MAST

�Doctorate (e.g., PhD, EdD) or Professional degree (e.g., MD, DO, DDS,

������ DVM, LLB, JD, RN, NP, PA).�

������ Enter DOCT or PROF: ______________

�0-11th grade.� Enter highest year completed: _____

�12th grade; no diploma.� Enter 12

�High school graduate or GED completed.� Enter HS or GED

�Some college credit, but no degree.� Enter SOCOL

�Associate degree (e.g. AA, AS).� Enter ASSOC

�Bachelor�s degree (e.g., BA AB, BS).� Enter BACH

�Master�s degree� (e.g., MA, MS, MEng, MEd, MSW, MBA).� Enter MAST

�Doctorate (e.g., PhD, EdD) or Professional degree� (e.g., MD, DO, DDS,

������ DVM, LLB, JD, RN, NP, PA).

������ Enter DOCT or PROF: ______________

Do not enter any identification by patient name or number on this worksheet.� Discard after use.

Do not retain the worksheet in the medical records or submit with the �Certificate of Live Birth� or the �Certificate of Fetal Death.�

 

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