Vital Records Birth and Fetal Death Reporting
1.0.0 - STU 1
Vital Records Birth and Fetal Death Reporting
1.0.0 - STU 1
This page is part of the Vital Records Birth and Fetal Death Reporting (v1.0.0: STU 1 on FHIR R4) based on FHIR R4. This is the current published version in its permanent home (it will always be available at this URL). For a full list of available versions, see the Directory of published versions 
<QuestionnaireResponse xmlns="http://hl7.org/fhir">
<id value="QuestionnaireResponse-mothers-live-birth-jada-quinn"/>
<meta>
<versionId value="10"/>
<lastUpdated value="2021-07-09T03:16:14.037+00:00"/>
<source value="#dijaEkhPzS4Eo0p1"/>
</meta>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml"><p><b>Generated Narrative</b></p><p><b>questionnaire</b>: <a href="http://hl7.org/fhir/us/bfdr/Questionnaire/Questionnaire-mothers-live-birth">http://hl7.org/fhir/us/bfdr/Questionnaire/Questionnaire-mothers-live-birth</a></p><p><b>status</b>: completed</p><p><b>subject</b>: <a href="Patient-patient-child-babyg-quinn.html">BabyG Quinn. Generated Summary: Medical Record Number: 9932702 (USUAL); Baby G Quinn ; gender: female; birthDate: 2019-02-12; 1</a></p><p><b>source</b>: <a href="Patient-patient-mother-jada-ann-quinn.html">Patient - Mother (Jada Ann Quinn). Generated Summary: Social Security number: 132225986 (USUAL), Medical Record Number: 1032702 (USUAL); Jada Ann Quinn (OFFICIAL), Jada Ann King (MAIDEN); Phone: 1-(404)555-1212, jadaann.quinn@example.com; gender: female; birthDate: 1985-01-15</a></p><blockquote><p><b>item</b></p><p><b>linkId</b>: mother-current-legal-name</p><p><b>text</b>: What is your current legal name?</p><blockquote><p><b>item</b></p><p><b>linkId</b>: mother-first-name</p><p><b>text</b>: First</p></blockquote><blockquote><p><b>item</b></p><p><b>linkId</b>: mother-middle-name</p><p><b>text</b>: Middle</p></blockquote><blockquote><p><b>item</b></p><p><b>linkId</b>: mother-last-name</p><p><b>text</b>: Last</p></blockquote></blockquote><blockquote><p><b>item</b></p><p><b>linkId</b>: child-name</p><p><b>text</b>: What will be your baby's legal name (as it should appear on the birth certificate)?</p><blockquote><p><b>item</b></p><p><b>linkId</b>: child-first-name</p><p><b>text</b>: First</p></blockquote><blockquote><p><b>item</b></p><p><b>linkId</b>: child-middle-name</p><p><b>text</b>: Middle</p></blockquote><blockquote><p><b>item</b></p><p><b>linkId</b>: child-last-name</p><p><b>text</b>: Last</p></blockquote></blockquote><blockquote><p><b>item</b></p><p><b>linkId</b>: mother-address</p><p><b>text</b>: Where do you usually live - that is - where is your household/residence located?</p><blockquote><p><b>item</b></p><p><b>linkId</b>: mother-nbr-street</p><p><b>text</b>: Complete number and street (do not enter rural route numbers)</p></blockquote><blockquote><p><b>item</b></p><p><b>linkId</b>: mother-city</p><p><b>text</b>: City, Town, or Location</p></blockquote><blockquote><p><b>item</b></p><p><b>linkId</b>: mother-county</p><p><b>text</b>: County</p></blockquote><blockquote><p><b>item</b></p><p><b>linkId</b>: mother-state</p><p><b>text</b>: State (or U.S. Territory, Canadian Province)</p></blockquote><blockquote><p><b>item</b></p><p><b>linkId</b>: mother-zip</p><p><b>text</b>: Zip Code</p></blockquote></blockquote><blockquote><p><b>item</b></p><p><b>linkId</b>: inside-city-limits</p><p><b>text</b>: Is this household inside city limits (inside the incorporated limits of the city, town, or location where you live)?</p><h3>Answers</h3><table class="grid"><tr><td>-</td><td><b>Value[x]</b></td></tr><tr><td>*</td><td><span title="{http://terminology.hl7.org/CodeSystem/v2-0532 Y}">Yes</span></td></tr></table></blockquote><blockquote><p><b>item</b></p><p><b>linkId</b>: mother-mail</p><p><b>text</b>: What is your mailing address</p><blockquote><p><b>item</b></p><p><b>linkId</b>: mother-mail-same</p><p><b>text</b>: Same as residence [Go to next question]</p></blockquote><blockquote><p><b>item</b></p><p><b>linkId</b>: mother-mail-nbr-street</p><p><b>text</b>: Complete number and street</p></blockquote><blockquote><p><b>item</b></p><p><b>linkId</b>: mother-mail-city</p><p><b>text</b>: City, Town, or Location</p></blockquote><blockquote><p><b>item</b></p><p><b>linkId</b>: mother-mail-state</p><p><b>text</b>: State (or U.S. Territory, Canadian Province)</p></blockquote><blockquote><p><b>item</b></p><p><b>linkId</b>: mother-mail-zip</p><p><b>text</b>: Zip Code</p></blockquote></blockquote><blockquote><p><b>item</b></p><p><b>linkId</b>: mother-dob</p><p><b>text</b>: What is your date of birth?</p><h3>Answers</h3><table class="grid"><tr><td>-</td><td><b>Value[x]</b></td></tr><tr><td>*</td><td>1985-01-15</td></tr></table></blockquote><blockquote><p><b>item</b></p><p><b>linkId</b>: mother-birthplace</p><p><b>text</b>: In what State, U.S. territory, or foreign country were you born? Please specify one of the following:</p><blockquote><p><b>item</b></p><p><b>linkId</b>: mother-birthplace-state</p><p><b>text</b>: State</p></blockquote></blockquote><blockquote><p><b>item</b></p><p><b>linkId</b>: mother-education</p><p><b>text</b>: What is the highest level of schooling that you have completed at the time of delivery? (Check the box that best describes your education. If you are currently enrolled, check the box that indicates the previous grade or highest degree received).</p><h3>Answers</h3><table class="grid"><tr><td>-</td><td><b>Value[x]</b></td></tr><tr><td>*</td><td><span title="{urn:oid:2.16.840.1.114222.4.5.274 PHC1455}">Doctorate Degree or Professional Degree</span></td></tr></table></blockquote><blockquote><p><b>item</b></p><p><b>linkId</b>: mother-ethnicity</p><p><b>text</b>: Are you Spanish/Hispanic/Latina? If not Spanish/Hispanic/Latina, check the “No” box. If Spanish/Hispanic/Latina, check the appropriate box.</p><blockquote><p><b>item</b></p><p><b>linkId</b>: mother-shl</p><p><b>text</b>: Are you Spanish/Hispanic/Latina</p></blockquote></blockquote><blockquote><p><b>item</b></p><p><b>linkId</b>: mother-race</p><p><b>text</b>: What is your race? (Please check one or more races to indicate what you consider yourself to be).</p><blockquote><p><b>item</b></p><p><b>linkId</b>: mother-race-category</p><p><b>text</b>: Race categories</p></blockquote><blockquote><p><b>item</b></p><p><b>linkId</b>: mother-detailed-race</p><p><b>text</b>: Extended race codes</p></blockquote></blockquote><blockquote><p><b>item</b></p><p><b>linkId</b>: receive-wic</p><p><b>text</b>: Did you receive WIC (Women, Infants and Children) food for yourself during this pregnancy?</p><h3>Answers</h3><table class="grid"><tr><td>-</td><td><b>Value[x]</b></td></tr><tr><td>*</td><td><span title="{http://terminology.hl7.org/CodeSystem/v2-0532 Y}">Yes</span></td></tr></table></blockquote><blockquote><p><b>item</b></p><p><b>linkId</b>: infertility-treatment</p><p><b>text</b>: Did this pregnancy result from infertility treatment? (If yes, please answer 12a and 12b)</p><blockquote><p><b>answer</b></p><p><b>value</b>: true</p><blockquote><p><b>item</b></p><p><b>linkId</b>: drugs-ai-ii</p><p><b>text</b>: If yes, did this pregnancy result from fertility-enhancing drugs, artificial insemination, or intrauterine insemination?</p></blockquote><blockquote><p><b>item</b></p><p><b>linkId</b>: art-ivf-gift</p><p><b>text</b>: If yes, did this pregnancy result from assisted reproductive technology (e.g., in-vitro fertilization (IVF), gamete intrafallopian transfer (GIFT))?</p></blockquote></blockquote></blockquote><blockquote><p><b>item</b></p><p><b>linkId</b>: mothers-height</p><p><b>text</b>: What is your height?</p><blockquote><p><b>item</b></p><p><b>linkId</b>: mothers-height-feet</p><p><b>text</b>: Feet</p></blockquote><blockquote><p><b>item</b></p><p><b>linkId</b>: mothers-height-inches</p><p><b>text</b>: Inches</p></blockquote></blockquote><blockquote><p><b>item</b></p><p><b>linkId</b>: mothers-prepregnancy-weight</p><p><b>text</b>: lbs</p><h3>Answers</h3><table class="grid"><tr><td>-</td><td><b>Value[x]</b></td></tr><tr><td>*</td><td>145 [lb_av]</td></tr></table></blockquote><blockquote><p><b>item</b></p><p><b>linkId</b>: mothers-smoking</p><p><b>text</b>: How many cigarettes OR packs of cigarettes did you smoke on an average day during each of the following time periods? If you NEVER smoked, enter zero for each time period.</p><blockquote><p><b>item</b></p><p><b>linkId</b>: mothers-smoking-3-months-prior</p><p><b>text</b>: Three months before pregnancy</p></blockquote><blockquote><p><b>item</b></p><p><b>linkId</b>: mothers-smoking-trimester-1</p><p><b>text</b>: First three months of pregnancy</p></blockquote><blockquote><p><b>item</b></p><p><b>linkId</b>: mothers-smoking-trimester-2</p><p><b>text</b>: Second three months of pregnancy</p></blockquote><blockquote><p><b>item</b></p><p><b>linkId</b>: mothers-smoking-trimester-3</p><p><b>text</b>: Third trimester of pregnancy</p></blockquote></blockquote><blockquote><p><b>item</b></p><p><b>linkId</b>: mother-prior-name</p><p><b>text</b>: What name did you use prior to your first marriage?</p><blockquote><p><b>item</b></p><p><b>linkId</b>: mother-prior-first-name</p><p><b>text</b>: First</p></blockquote><blockquote><p><b>item</b></p><p><b>linkId</b>: mother-prior-middle-name</p><p><b>text</b>: Middle</p></blockquote><blockquote><p><b>item</b></p><p><b>linkId</b>: mother-prior-last-name</p><p><b>text</b>: Last</p></blockquote></blockquote><blockquote><p><b>item</b></p><p><b>linkId</b>: married-conception</p><p><b>text</b>: Were you married at the time you conceived this child, at the time of birth, or at any time between conception and giving birth? [If yes, please go to question 19; If no, please see below]</p><h3>Answers</h3><table class="grid"><tr><td>-</td><td><b>Value[x]</b></td></tr><tr><td>*</td><td>true</td></tr></table></blockquote><blockquote><p><b>item</b></p><p><b>linkId</b>: father-current-legal-name</p><p><b>text</b>: What is the current legal name of your baby's father?</p><blockquote><p><b>item</b></p><p><b>linkId</b>: father-first-name</p><p><b>text</b>: First</p></blockquote><blockquote><p><b>item</b></p><p><b>linkId</b>: father-middle-name</p><p><b>text</b>: Middle</p></blockquote><blockquote><p><b>item</b></p><p><b>linkId</b>: father-last-name</p><p><b>text</b>: Last</p></blockquote></blockquote><blockquote><p><b>item</b></p><p><b>linkId</b>: father-dob</p><p><b>text</b>: What the father's date of birth?</p><h3>Answers</h3><table class="grid"><tr><td>-</td><td><b>Value[x]</b></td></tr><tr><td>*</td><td>1983-09-27</td></tr></table></blockquote><blockquote><p><b>item</b></p><p><b>linkId</b>: father-birthplace</p><p><b>text</b>: In what State, U.S. territory, or foreign country was the father born? Please specify one of the following:</p><blockquote><p><b>item</b></p><p><b>linkId</b>: father-birthplace-state</p><p><b>text</b>: State</p></blockquote></blockquote><blockquote><p><b>item</b></p><p><b>linkId</b>: father-education</p><p><b>text</b>: What is the highest level of schooling that the father will have completed at the time of delivery? (Check the box that best describes his education. If he is currently enrolled, check the box that indicates the previous grade or highest degree received).</p><h3>Answers</h3><table class="grid"><tr><td>-</td><td><b>Value[x]</b></td></tr><tr><td>*</td><td><span title="{urn:oid:2.16.840.1.114222.4.5.274 PHC1455}">Doctorate Degree or Professional Degree</span></td></tr></table></blockquote><blockquote><p><b>item</b></p><p><b>linkId</b>: father-ethnicity</p><p><b>text</b>: Is the father Spanish/Hispanic/Latina? If not Spanish/Hispanic/Latina, check the “No” box. If Spanish/Hispanic/Latina, check the appropriate box.</p><blockquote><p><b>item</b></p><p><b>linkId</b>: father-shl</p><p><b>text</b>: Is the father Spanish/Hispanic/Latina</p></blockquote></blockquote><blockquote><p><b>item</b></p><p><b>linkId</b>: father-race</p><p><b>text</b>: What is the father's race? (Please check one or more races to indicate what he considers himself to be).</p><blockquote><p><b>item</b></p><p><b>linkId</b>: father-race-category</p><p><b>text</b>: Race categories</p></blockquote></blockquote><blockquote><p><b>item</b></p><p><b>linkId</b>: parents-ssn</p><p><b>text</b>: Furnishing parent(s) Social Security Number(s) (SSNs) is required by Federal Law, 42 USC 405(c) (section 205(c) of the Social Security Act). The number(s) will be made available to the (State Social Services Agency) to assist with child support enforcement activities and to the Internal Revenue Service for the purpose of determining Earned Income Tax Credit compliance.</p><blockquote><p><b>item</b></p><p><b>linkId</b>: mother-ssn</p><p><b>text</b>: What is your Social Security Number?</p></blockquote><blockquote><p><b>item</b></p><p><b>linkId</b>: father-ssn</p><p><b>text</b>: What is the father’s Social Security Number? If you are not married, and if a paternity acknowledgment has not been completed, leave this item blank.</p></blockquote></blockquote><blockquote><p><b>item</b></p><p><b>linkId</b>: baby-ssn</p><p><b>text</b>: Do you want a Social Security Number issued for your baby? [If yes, please sign request below</p><h3>Answers</h3><table class="grid"><tr><td>-</td><td><b>Value[x]</b></td></tr><tr><td>*</td><td>false</td></tr></table></blockquote><blockquote><p><b>item</b></p><p><b>linkId</b>: informant-name</p><p><b>text</b>: If other than the mother, what is the name of the person providing information for this worksheet?</p><blockquote><p><b>item</b></p><p><b>linkId</b>: informant-first-name</p><p><b>text</b>: First</p></blockquote><blockquote><p><b>item</b></p><p><b>linkId</b>: informant-last-name</p><p><b>text</b>: Last</p></blockquote></blockquote><blockquote><p><b>item</b></p><p><b>linkId</b>: informant-relationship</p><p><b>text</b>: What is your relationship to the baby's mother?</p><h3>Answers</h3><table class="grid"><tr><td>-</td><td><b>Value[x]</b></td></tr><tr><td>*</td><td><span title="{urn:oid:2.16.840.1.114222.4.5.274 PHC1497}">Other relative</span></td></tr></table></blockquote></div>
</text>
<questionnaire
value="http://hl7.org/fhir/us/bfdr/Questionnaire/Questionnaire-mothers-live-birth"/>
<status value="completed"/>
<subject>
<reference value="Patient/patient-child-babyg-quinn"/>
<display value="BabyG Quinn"/>
</subject>
<source>
<reference value="Patient/patient-mother-jada-ann-quinn"/>
<display value="Patient - Mother (Jada Ann Quinn)"/>
</source>
<item>
<linkId value="mother-current-legal-name"/>
<text value="What is your current legal name?"/>
<item>
<linkId value="mother-first-name"/>
<text value="First"/>
<answer>
<valueString value="Jada"/>
</answer>
</item>
<item>
<linkId value="mother-middle-name"/>
<text value="Middle"/>
<answer>
<valueString value="Ann"/>
</answer>
</item>
<item>
<linkId value="mother-last-name"/>
<text value="Last"/>
<answer>
<valueString value="Quinn"/>
</answer>
</item>
</item>
<item>
<linkId value="child-name"/>
<text
value="What will be your baby's legal name (as it should appear on the birth certificate)?"/>
<item>
<linkId value="child-first-name"/>
<text value="First"/>
<answer>
<valueString value="Baby"/>
</answer>
</item>
<item>
<linkId value="child-middle-name"/>
<text value="Middle"/>
<answer>
<valueString value="G"/>
</answer>
</item>
<item>
<linkId value="child-last-name"/>
<text value="Last"/>
<answer>
<valueString value="Quinn"/>
</answer>
</item>
</item>
<item>
<linkId value="mother-address"/>
<text
value="Where do you usually live - that is - where is your household/residence located?"/>
<item>
<linkId value="mother-nbr-street"/>
<text
value="Complete number and street (do not enter rural route numbers)"/>
<answer>
<valueString value="1875 West Morton Avenue"/>
</answer>
</item>
<item>
<linkId value="mother-city"/>
<text value="City, Town, or Location"/>
<answer>
<valueString value="Salt Lake City"/>
</answer>
</item>
<item>
<linkId value="mother-county"/>
<text value="County"/>
<answer>
<valueString value="Salt Lake"/>
</answer>
</item>
<item>
<linkId value="mother-state"/>
<text value="State (or U.S. Territory, Canadian Province)"/>
<answer>
<valueString value="UT"/>
</answer>
</item>
<item>
<linkId value="mother-zip"/>
<text value="Zip Code"/>
<answer>
<valueString value="84116"/>
</answer>
</item>
</item>
<item>
<linkId value="inside-city-limits"/>
<text
value="Is this household inside city limits (inside the incorporated limits of the city, town, or location where you live)?"/>
<answer>
<valueCoding>
<system value="http://terminology.hl7.org/CodeSystem/v2-0532"/>
<code value="Y"/>
<display value="Yes"/>
</valueCoding>
</answer>
</item>
<item>
<linkId value="mother-mail"/>
<text value="What is your mailing address"/>
<item>
<linkId value="mother-mail-same"/>
<text value="Same as residence [Go to next question]"/>
<answer>
<valueBoolean value="false"/>
</answer>
</item>
<item>
<linkId value="mother-mail-nbr-street"/>
<text value="Complete number and street"/>
<answer>
<valueString value="1848 South 1300 East"/>
</answer>
</item>
<item>
<linkId value="mother-mail-city"/>
<text value="City, Town, or Location"/>
<answer>
<valueString value="Salt Lake City"/>
</answer>
</item>
<item>
<linkId value="mother-mail-state"/>
<text value="State (or U.S. Territory, Canadian Province)"/>
<answer>
<valueString value="UT"/>
</answer>
</item>
<item>
<linkId value="mother-mail-zip"/>
<text value="Zip Code"/>
<answer>
<valueString value="84401"/>
</answer>
</item>
</item>
<item>
<linkId value="mother-dob"/>
<text value="What is your date of birth?"/>
<answer>
<valueDate value="1985-01-15"/>
</answer>
</item>
<item>
<linkId value="mother-birthplace"/>
<text
value="In what State, U.S. territory, or foreign country were you born? Please specify one of the following:"/>
<item>
<linkId value="mother-birthplace-state"/>
<text value="State"/>
<answer>
<valueString value="UT"/>
</answer>
</item>
</item>
<item>
<linkId value="mother-education"/>
<text
value="What is the highest level of schooling that you have completed at the time of delivery? (Check the box that best describes your education. If you are currently enrolled, check the box that indicates the previous grade or highest degree received)."/>
<answer>
<valueCoding>
<system value="urn:oid:2.16.840.1.114222.4.5.274"/>
<code value="PHC1455"/>
<display value="Doctorate Degree or Professional Degree"/>
</valueCoding>
</answer>
</item>
<item>
<linkId value="mother-ethnicity"/>
<text
value="Are you Spanish/Hispanic/Latina? If not Spanish/Hispanic/Latina, check the “No” box. If Spanish/Hispanic/Latina, check the appropriate box."/>
<item>
<linkId value="mother-shl"/>
<text value="Are you Spanish/Hispanic/Latina"/>
<answer>
<valueCoding>
<system value="urn:oid:2.16.840.1.113883.6.238"/>
<code value="2186-5"/>
<display value="Not Hispanic or Latino"/>
</valueCoding>
</answer>
</item>
</item>
<item>
<linkId value="mother-race"/>
<text
value="What is your race? (Please check one or more races to indicate what you consider yourself to be)."/>
<item>
<linkId value="mother-race-category"/>
<text value="Race categories"/>
<answer>
<valueCoding>
<system value="urn:oid:2.16.840.1.113883.6.238"/>
<code value="2106-3"/>
<display value="White"/>
</valueCoding>
</answer>
</item>
<item>
<linkId value="mother-detailed-race"/>
<text value="Extended race codes"/>
<answer>
<valueCoding>
<system value="urn:oid:2.16.840.1.113883.6.238"/>
<code value="1002-5"/>
<display value="American Indian or Alaska Native"/>
</valueCoding>
</answer>
</item>
</item>
<item>
<linkId value="receive-wic"/>
<text
value="Did you receive WIC (Women, Infants and Children) food for yourself during this pregnancy?"/>
<answer>
<valueCoding>
<system value="http://terminology.hl7.org/CodeSystem/v2-0532"/>
<code value="Y"/>
<display value="Yes"/>
</valueCoding>
</answer>
</item>
<item>
<linkId value="infertility-treatment"/>
<text
value="Did this pregnancy result from infertility treatment? (If yes, please answer 12a and 12b)"/>
<answer>
<valueBoolean value="true"/>
<item>
<linkId value="drugs-ai-ii"/>
<text
value="If yes, did this pregnancy result from fertility-enhancing drugs, artificial insemination, or intrauterine insemination?"/>
<answer>
<valueBoolean value="false"/>
</answer>
</item>
<item>
<linkId value="art-ivf-gift"/>
<text
value="If yes, did this pregnancy result from assisted reproductive technology (e.g., in-vitro fertilization (IVF), gamete intrafallopian transfer (GIFT))?"/>
<answer>
<valueBoolean value="true"/>
</answer>
</item>
</answer>
</item>
<item>
<linkId value="mothers-height"/>
<text value="What is your height?"/>
<item>
<linkId value="mothers-height-feet"/>
<text value="Feet"/>
<answer>
<valueQuantity>
<value value="5"/>
<unit value="ft"/>
<system value="http://unitsofmeasure.org"/>
<code value="ft"/>
</valueQuantity>
</answer>
</item>
<item>
<linkId value="mothers-height-inches"/>
<text value="Inches"/>
<answer>
<valueQuantity>
<value value="7"/>
<unit value="[in_i]"/>
<system value="http://unitsofmeasure.org"/>
<code value="[in_i]"/>
</valueQuantity>
</answer>
</item>
</item>
<item>
<linkId value="mothers-prepregnancy-weight"/>
<text value="lbs"/>
<answer>
<valueQuantity>
<value value="145"/>
<unit value="[lb_av]"/>
<system value="http://unitsofmeasure.org"/>
<code value="[lb_av]"/>
</valueQuantity>
</answer>
</item>
<item>
<linkId value="mothers-smoking"/>
<text
value="How many cigarettes OR packs of cigarettes did you smoke on an average day during each of the following time periods? If you NEVER smoked, enter zero for each time period."/>
<item>
<linkId value="mothers-smoking-3-months-prior"/>
<text value="Three months before pregnancy"/>
<item>
<linkId value="mothers-smoking-3-months-prior-cig"/>
<text value="# of cigarettes*"/>
<answer>
<valueInteger value="0"/>
</answer>
</item>
<item>
<linkId value="mothers-smoking-3-months-prior-pck"/>
<text value="# of packs"/>
<answer>
<valueInteger value="1"/>
</answer>
</item>
</item>
<item>
<linkId value="mothers-smoking-trimester-1"/>
<text value="First three months of pregnancy"/>
<item>
<linkId value="mothers-smoking-trimester-1-cig"/>
<text value="# of cigarettes*"/>
<answer>
<valueInteger value="3"/>
</answer>
</item>
<item>
<linkId value="mothers-smoking-trimester-1-pck"/>
<text value="# of packs"/>
<answer>
<valueInteger value="0"/>
</answer>
</item>
</item>
<item>
<linkId value="mothers-smoking-trimester-2"/>
<text value="Second three months of pregnancy"/>
<item>
<linkId value="mothers-smoking-trimester-2-cig"/>
<text value="# of cigarettes*"/>
<answer>
<valueInteger value="1"/>
</answer>
</item>
<item>
<linkId value="mothers-smoking-trimester-2-pck"/>
<text value="# of packs"/>
<answer>
<valueInteger value="0"/>
</answer>
</item>
</item>
<item>
<linkId value="mothers-smoking-trimester-3"/>
<text value="Third trimester of pregnancy"/>
<item>
<linkId value="mothers-smoking-trimester-3-cig"/>
<text value="# of cigarettes*"/>
<answer>
<valueInteger value="0"/>
</answer>
</item>
<item>
<linkId value="mothers-smoking-trimester-3-pck"/>
<text value="# of packs"/>
<answer>
<valueInteger value="0"/>
</answer>
</item>
</item>
</item>
<item>
<linkId value="mother-prior-name"/>
<text value="What name did you use prior to your first marriage?"/>
<item>
<linkId value="mother-prior-first-name"/>
<text value="First"/>
<answer>
<valueString value="Jada"/>
</answer>
</item>
<item>
<linkId value="mother-prior-middle-name"/>
<text value="Middle"/>
<answer>
<valueString value="Ann"/>
</answer>
</item>
<item>
<linkId value="mother-prior-last-name"/>
<text value="Last"/>
<answer>
<valueString value="King"/>
</answer>
</item>
</item>
<item>
<linkId value="married-conception"/>
<text
value="Were you married at the time you conceived this child, at the time of birth, or at any time between conception and giving birth? [If yes, please go to question 19; If no, please see below]"/>
<answer>
<valueBoolean value="true"/>
</answer>
</item>
<item>
<linkId value="father-current-legal-name"/>
<text value="What is the current legal name of your baby's father?"/>
<item>
<linkId value="father-first-name"/>
<text value="First"/>
<answer>
<valueString value="James"/>
</answer>
</item>
<item>
<linkId value="father-middle-name"/>
<text value="Middle"/>
<answer>
<valueString value="Brandon"/>
</answer>
</item>
<item>
<linkId value="father-last-name"/>
<text value="Last"/>
<answer>
<valueString value="Quinn"/>
</answer>
</item>
</item>
<item>
<linkId value="father-dob"/>
<text value="What the father's date of birth?"/>
<answer>
<valueDate value="1983-09-27"/>
</answer>
</item>
<item>
<linkId value="father-birthplace"/>
<text
value="In what State, U.S. territory, or foreign country was the father born? Please specify one of the following:"/>
<item>
<linkId value="father-birthplace-state"/>
<text value="State"/>
<answer>
<valueString value="NY"/>
</answer>
</item>
</item>
<item>
<linkId value="father-education"/>
<text
value="What is the highest level of schooling that the father will have completed at the time of delivery? (Check the box that best describes his education. If he is currently enrolled, check the box that indicates the previous grade or highest degree received)."/>
<answer>
<valueCoding>
<system value="urn:oid:2.16.840.1.114222.4.5.274"/>
<code value="PHC1455"/>
<display value="Doctorate Degree or Professional Degree"/>
</valueCoding>
</answer>
</item>
<item>
<linkId value="father-ethnicity"/>
<text
value="Is the father Spanish/Hispanic/Latina? If not Spanish/Hispanic/Latina, check the “No” box. If Spanish/Hispanic/Latina, check the appropriate box."/>
<item>
<linkId value="father-shl"/>
<text value="Is the father Spanish/Hispanic/Latina"/>
<answer>
<valueCoding>
<system value="urn:oid:2.16.840.1.113883.6.238"/>
<code value="2186-5"/>
<display value="Not Hispanic or Latino"/>
</valueCoding>
</answer>
</item>
</item>
<item>
<linkId value="father-race"/>
<text
value="What is the father's race? (Please check one or more races to indicate what he considers himself to be)."/>
<item>
<linkId value="father-race-category"/>
<text value="Race categories"/>
<answer>
<valueCoding>
<system value="urn:oid:2.16.840.1.113883.6.238"/>
<code value="2106-3"/>
<display value="White"/>
</valueCoding>
</answer>
</item>
</item>
<item>
<linkId value="parents-ssn"/>
<text
value="Furnishing parent(s) Social Security Number(s) (SSNs) is required by Federal Law, 42 USC 405(c) (section 205(c) of the Social Security Act). The number(s) will be made available to the (State Social Services Agency) to assist with child support enforcement activities and to the Internal Revenue Service for the purpose of determining Earned Income Tax Credit compliance."/>
<item>
<linkId value="mother-ssn"/>
<text value="What is your Social Security Number?"/>
<answer>
<valueString value="132-22-5986"/>
</answer>
</item>
<item>
<linkId value="father-ssn"/>
<text
value="What is the father’s Social Security Number? If you are not married, and if a paternity acknowledgment has not been completed, leave this item blank."/>
<answer>
<valueString value="132-22-5987"/>
</answer>
</item>
</item>
<item>
<linkId value="baby-ssn"/>
<text
value="Do you want a Social Security Number issued for your baby? [If yes, please sign request below"/>
<answer>
<valueBoolean value="false"/>
</answer>
</item>
<item>
<linkId value="informant-name"/>
<text
value="If other than the mother, what is the name of the person providing information for this worksheet?"/>
<item>
<linkId value="informant-first-name"/>
<text value="First"/>
<answer>
<valueString value="Jane"/>
</answer>
</item>
<item>
<linkId value="informant-last-name"/>
<text value="Last"/>
<answer>
<valueString value="King"/>
</answer>
</item>
</item>
<item>
<linkId value="informant-relationship"/>
<text value="What is your relationship to the baby's mother?"/>
<answer>
<valueCoding>
<system value="urn:oid:2.16.840.1.114222.4.5.274"/>
<code value="PHC1497"/>
<display value="Other relative"/>
</valueCoding>
</answer>
</item>
</QuestionnaireResponse>
IG © 2020+ HL7 International - Public Health Work Group. Package hl7.fhir.us.bfdr#1.0.0 based on FHIR 4.0.1. Generated 2021-10-22
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