Birth And Fetal Death (BFDR) FHIR Implementation Guide
2.0.0 - STU2 United States of America flag

This page is part of the Vital Records Birth and Fetal Death Reporting (v2.0.0: STU2) based on FHIR (HL7® FHIR® Standard) 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

Example QuestionnaireResponse: QuestionnaireResponse - Mother's Worksheet for Child's Birth Certificate: Jada Ann Quinn

Generated Narrative: QuestionnaireResponse QuestionnaireResponse-mothers-live-birth-jada-quinn

LinkIDTextDefinitionAnswerdoco
.. QuestionnaireResponse-mothers-live-birth-jada-quinnQuestionnaire:Questionnaire - Mother's Worksheet for Child's Birth Certificate
... mother-current-legal-nameWhat is your current legal name?
.... mother-first-nameFirstJada
.... mother-middle-nameMiddleAnn
.... mother-last-nameLastQuinn
... child-nameWhat will be your baby's legal name (as it should appear on the birth certificate)?
.... child-first-nameFirstBaby
.... child-middle-nameMiddleG
.... child-last-nameLastQuinn
... mother-addressWhere do you usually live - that is - where is your household/residence located?
.... mother-nbr-streetComplete number and street (do not enter rural route numbers)1875 West Morton Avenue
.... mother-cityCity, Town, or LocationSalt Lake City
.... mother-countyCountySalt Lake
.... mother-stateState (or U.S. Territory, Canadian Province)UT
.... mother-zipZip Code84116
... inside-city-limitsIs this household inside city limits (inside the incorporated limits of the city, town, or location where you live)?v2 Y/N Indicator Y: Yes
... mother-mailWhat is your mailing address
.... mother-mail-sameSame as residence [Go to next question]false
.... mother-mail-nbr-streetComplete number and street1848 South 1300 East
.... mother-mail-cityCity, Town, or LocationSalt Lake City
.... mother-mail-stateState (or U.S. Territory, Canadian Province)UT
.... mother-mail-zipZip Code84401
... mother-dobWhat is your date of birth?1985-01-15
... mother-birthplaceIn what State, U.S. territory, or foreign country were you born? Please specify one of the following:
.... mother-birthplace-stateStateUT
... mother-educationWhat 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).Education Level POSTG: Doctoral or post graduate education
... mother-ethnicityfalse
... mother-race
.... mother-race-whiteWhitetrue
.... mother-race-aianAmerican Indian or Alaskan Nativetrue
... receive-wicDid you receive WIC (Women, Infants and Children) food for yourself during this pregnancy?v2 Y/N Indicator Y: Yes
... infertility-treatmentDid this pregnancy result from infertility treatment? (If yes, please answer 12a and 12b)true
.... drugs-ai-iiIf yes, did this pregnancy result from fertility-enhancing drugs, artificial insemination, or intrauterine insemination?false
.... art-ivf-giftIf yes, did this pregnancy result from assisted reproductive technology (e.g., in-vitro fertilization (IVF), gamete intrafallopian transfer (GIFT))?true
... mothers-heightWhat is your height?
.... mothers-height-feetFeet5 ft (Details: UCUM codeft = 'ft')
.... mothers-height-inchesInches7 [in_i] (Details: UCUM code[in_i] = '[in_i]')
... mothers-prepregnancy-weight145 [lb_av] (Details: UCUM code[lb_av] = '[lb_av]')
... mothers-smokingHow 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.
.... mothers-smoking-3-months-priorThree months before pregnancy
..... mothers-smoking-3-months-prior-cig# of cigarettes*0
..... mothers-smoking-3-months-prior-pck# of packs1
.... mothers-smoking-trimester-1First three months of pregnancy
..... mothers-smoking-trimester-1-cig# of cigarettes*3
..... mothers-smoking-trimester-1-pck# of packs0
.... mothers-smoking-trimester-2Second three months of pregnancy
..... mothers-smoking-trimester-2-cig# of cigarettes*1
..... mothers-smoking-trimester-2-pck# of packs0
.... mothers-smoking-trimester-3Third trimester of pregnancy
..... mothers-smoking-trimester-3-cig# of cigarettes*0
..... mothers-smoking-trimester-3-pck# of packs0
... mother-prior-nameWhat name did you use prior to your first marriage?
.... mother-prior-first-nameFirstJada
.... mother-prior-middle-nameMiddleAnn
.... mother-prior-last-nameLastKing
... married-conceptionWere 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]true
... father-current-legal-nameWhat is the current legal name of your baby's father?
.... father-first-nameFirstJames
.... father-middle-nameMiddleBrandon
.... father-last-nameLastQuinn
... father-dobWhat the father's date of birth?1983-09-27
... father-birthplaceIn what State, U.S. territory, or foreign country was the father born? Please specify one of the following:
.... father-birthplace-stateStateNY
... father-educationWhat 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).Education Level POSTG: Doctoral or post graduate education
... father-ethnicityfalse
... father-race
.... father-race-whiteWhitetrue
... parents-ssnFurnishing 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.
.... mother-ssnWhat is your Social Security Number?132-22-5986
.... father-ssnWhat 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.132-22-5987
... baby-ssnDo you want a Social Security Number issued for your baby? [If yes, please sign request belowfalse
... informant-nameIf other than the mother, what is the name of the person providing information for this worksheet?
.... informant-first-nameFirstJane
.... informant-last-nameLastKing
... informant-relationshipWhat is your relationship to the baby's mother?Local BFDR Codes rel_otherrelative: Other relative

doco Documentation for this format