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.
0-11^th grade. Enter highest year completed: _____ 12^th 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: ______________		0-11^th grade. Enter highest year completed: _____ 12^th 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.”

VS 10B (Rev. 1/06)

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