WSR 02-16-100

PROPOSED RULES

STATE BOARD OF HEALTH


(Department of Health)

[ Filed August 7, 2002, 11:56 a.m. ]

Original Notice.

Preproposal statement of inquiry was filed as WSR 01-08-090.

Title of Rule: Chapter 246-491 WAC, Vital statistics -- Certificates.

Purpose: These rules identify the information that the Department of Health collects from birth, death, fetal death, marriage, divorce and separation certificates. The State Board of Health identifies the information collected from the confidential sections of these certificates, and the Department of Health identifies the information collected from the public section of the certificates.

Other Identifying Information: The information collected on the certificates is based on the United States forms of live birth and fetal death, which are developed by the United States Department of Health and Human Services, National Center for Health Statistics.

Statutory Authority for Adoption: WAC 246-491-001 Purpose is RCW 43.70.150, chapter 70.58 RCW; WAC 246-491-010 Definitions is RCW 43.70.150; WAC 246-491-029 Information collected on the confidential section of live birth and fetal death certificates and 246-491-039 Confidential information on state of Washington live birth and fetal death certificates under chapter 70.58 RCW is RCW 70.58.055; and WAC 246-491-149 Information collected on the legal or public section of certificates is RCW 43.70.150.

Statute Being Implemented: Chapter 70.58 RCW.

Summary: The proposal incorporates federal changes to birth, death, and fetal death certificates. The entire chapter is also reformatted to improve clarity.

Reasons Supporting Proposal: The proposal removes items that are no longer relevant, not being used, or that cannot be reliably collected. The proposal will enable the department to add items that address emerging health issues.

Name of Agency Personnel Responsible for Drafting: John Whitbeck, Center of Health Statistics, (360) 236-4321; Implementation: Phil Freeman, Center of Health Statistics, (360) 236-4330; and Enforcement: Teresa Jennings, Center of Health Statistics, (360) 236-4307.

Name of Proponent: State Board of Health, Washington Department of Health, governmental.

Rule is not necessitated by federal law, federal or state court decision.

Explanation of Rule, its Purpose, and Anticipated Effects: The proposal incorporates federal changes to the birth, death, and fetal death certificates. The proposal removes items that are no longer relevant, not being used, or that cannot be reliably collected. The proposal adds items that address emerging health issues. The proposal also changes the format of the chapter so that it is easier to read and understand. The outcome of the rule change will be the collection of more relevant data, and increased clarity within the rule.

Proposal Changes the Following Existing Rules: The change adds new items, deletes some previously added, and deletes some items to birth, fetal death, and death certificates. The proposal also changes the format of the information described within the rule.

A small business economic impact statement has been prepared under chapter 19.85 RCW.

Small Business Economic Impact Statement

This rule has been reviewed. A small business economic impact statement is required due to greater than minor costs for reporting amendments. Cost minimizing features have been included.

I. What does the rule or rule amendment require? The rule requires that hospitals, funeral directors, and certifiers of causes of death collect information for birth, fetal death and death certificates that are slightly different from the United States standard certificates, but each on a form that is constructed and delivered by the Center for Health Statistics/DOH. The birth certificate data are collected by a web instrument form data that the hospitals and birthing centers generate on site from hospital records, and a work sheet filled in by parents.

The death certificate, which is being approved by this rule change, will not be in effect until January 1, 2004. Prior to that time, a mandatory legislative feasibility study on the proposed electronic collection of death certificates (EDRS) must be completed by December 31, 2002. This report to the legislature will discuss potential impacts, costs and savings of affected small businesses.

The rule to be amended defines the items included on vital statistics certificates provided by the Washington State Center for Health Statistics (CHS). This amendment is necessary because of recent changes in federal recommendations cited in Washington state law. RCW 70.58.055 requires CHS to use on its vital statistics certificates, at a minimum, the items recommended by the National Center for Health Statistics (NCHS). NCHS periodically revises its recommendations, to increase the relevance and quality of data collected on the certificates. Historically the national revision prompts a revision of state certificates, to ensure nation-wide comparability and take advantage of improvements suggested by national reviews of the certificate items. Implementation of these recommendations for the birth and fetal death certificates is expected to take effect in January 2003. Implementation for the death certificate will be January 1, 2004.

The current rule changes modify the certificates only slightly. All persons or business affected have filled in and submitted these certificates as a part of their business practice since beginning their business. Birth certificate data are collected by a web instrument from data that the hospitals and birthing centers generate onsite from hospital records, and a work sheet filled in by parents. The death certificate, which is being approved by this rule change, will not be in effect until January 1, 2004. The change will not affect the methods by which funeral directors collect their information, since they rely upon informants -- family members of the deceased, doctors, medical examiners, nursing home or hospital staff. However, additions, changes or deletions to each certificate were examined to determine if there are any disproportionate burdens to small business. There are two additions new to the certificate (tribal reservation name and county of injury). Based on other analyses, these items would add fifteen seconds to the completion time of each death certificate. There are six items deleted from the certificate (License number of funeral director, Date pronounced dead, Time pronounced dead, Signature of person pronouncing death, License number of person pronouncing death, and Date person pronouncing death signed). As a conservative estimate, the timesavings from the deletions would be at least thirty seconds per death certificate. Thus, the net change is fifteen seconds less for the new death certificate. For this reason, an item analysis for death certificates was not done.

Industries affected: This rule has been evaluated and the amendments may affect the following 4 digit SIC codes. Midwives and hospitals (8049, 8062, 8069) are affected primarily by the birth certificate requirements. The remaining SICs (7261, 8011, 8031), are affected primarily by the fetal death certificate.

7261 - Funeral homes

8049 - Midwives & Clinics of physician assistants

8062 - General medical & surgical hospitals

8069 - Cancer hospitals, chronic disease hospitals, maternity hospitals, etc.

8011 - Clinics of physicians & Pathologists

8031 - Clinics of osteopathic physicians

II. Rule costs: Most of the rule amendment costs are exempt due to the fact that the rule adopts a federal or state law by reference. The remaining costs involving those parts of the rules that delete or add items, which may not be exempt, have been analyzed based on the time required to fill out the added information.

Reporting Costs: All of the costs of the rule amendments are reporting. For a breakdown of the labor cost of the reporting requirements see Table 1. For a worst case analysis the labor cost of the reporting requirement for a large hospital is $1,582 and for a small hospital is $12.51 per year. The large hospital is assumed to have 4,967 births and the small birthing hospital is assumed to have sixteen births per year.1 Large hospitals generally have computer systems that automatically query for data and data entry is fast and done by a medical assistant with an hourly wage of $12.07. The small birthing centers may have the data entry done by the RN who helped with delivery. The average hourly wage for the RN is $24.22.2

The agency used an expert opinion3 to estimate the time it takes to enter data in the new data system that is being made available to all birthing centers.

The cost for fetal death certificates is minor. Since they are rare it is not considered here.

Table 1
Estimate of Cost of Rule for proposed 2003 Washington State Birth Certificate

and U.S. Standard Certificate

Required by Added Large Hospitals Small Hospitals
Federal DOH time per # Births/yr 4967 # Births/yr 16
Reg. Prop. Status birth Cost/birth1 Total $ Cost/birth2 Total $
Changes to existing items:
Place where birth occurred: add 'enroute' Yes -- Exempt
Mother married? Split into two questions: Is mother married to the father? If no, was mother married to anyone during this pregnancy? Yes -- Exempt -- -- -- --
Mother's education: If 8th grade or less, add line to specify exact years of education Yes -- Exempt
Father's education: If 8th grade or less, add line to specify exact years of education Yes -- Exempt -- -- -- -- --
Source of payment for delivery: Add 'Indian Health' and 'CHAMPUS' Yes -- Exempt
Risk factors in this pregnancy: Add 'Group B streptococcus culture positive' Yes -- Exempt -- -- -- -- --
Infections present and/or treated during this pregnancy: Add 'HIV infection' and 'Other (specify)' Yes Exempt -- -- -- -- --
Added items:
Tribal reservation name (if applicable) Yes Eligible 10 0.0335 166.39 0.0673 1.08
Mother's telephone number Yes Eligible 5 0.0168 83.45 0.0336 0.54
Length of time at mother's current residence Yes Eligible 5 0.0168 83.45 0.0336 0.54
Mother's occupation and industry Yes Eligible 10 0.0335 166.39 0.0673 1.08
Father's occupation and industry Yes Eligible 10 0.0335 166.39 0.0673 1.08
Optional signature line for person reviewing the worksheet Yes Eligible 0 0 0 0 0
Infant head circumference Yes Eligible 60 0.2012 999.36 0.4037 6.46
Deleted items:
Date filed by registrar Yes Eligible -5 -0.0168 -83.45 -0.0336 -0.54
Total 95 0.3185 1581.99 0.6391 10.23
1Large hospital costs estimated based on work done by a "medical assistant," 31-9092, mean annual wage $12.07/hour.
2Small hospital costs estimated based on work done by a "registered nurse," 29-1111, mean annual wage $24.22/hour.

III. Is the cost disproportionate? This rule amendment has been reviewed and the cost is disproportionately high for small business. The cost for large hospitals is estimated to be $.78 per employee and for small birthing centers $.92 per employee.

Given that the cost is disproportionate for small business DOH must minimize the costs.

IV. What cost minimizing features were included?

A. Reducing, modifying, or eliminating substantive regulatory requirements: DOH eliminated one item from the birth certificate, requiring the date filed by the registrar.

B. Simplifying, reducing, or eliminating record-keeping and reporting requirements: Making the computer system web accessible means that it is far easier for the hospitals and other users to maintain records and file them than it was.

C. Reducing the frequency of inspections: There are no inspections.

D. Delaying compliance timetables: There is no change but DOH has made it easier to comply on time with the new WEB system.

E. Reducing or modifying fine schedules for noncompliance: There are no fines.

V. How will you involve small business in the rule making? Information was sent to approximately 1,960 hospitals, birth centers and other interested parties. Information was also placed on the Department of Health website with forms for comment. Those without access to the internet may request a packet of information through the United States mail.

The same people and organizations will be notified of the hearing scheduled for September 11, 2002.

1Some hospitals have one or two births but these are generally emergencies.

2See sources on Table 1.

3Pat Starzyk, Research Investigator, Center for Health Statistics.

A copy of the statement may be obtained by writing to Suzanne Shillander, Center for Health Statistics, P.O. Box 47814, Olympia, WA 98504-7814, phone (360) 236-4308, fax (360) 753-4135.

RCW 34.05.328 does not apply to this rule adoption. Credentialed health care providers can be disciplined and sanctioned under RCW 18.130.180(7) of the Uniform Disciplinary Act for failing to comply with laws that apply to the practice of the particular profession. Because physicians and midwives are subject to the reporting requirements in RCW 70.58.080, this rule qualifies as legislatively significant.

Hearing Location: 2002 Mount Vernon Best Western Cottontree Inn & Conference Center, 2401 Riverside Drive, Mount Vernon, WA 98273, phone (360) 428-5678, fax (360) 848-5285, on September 11, 2002, at 10:00 a.m.

Assistance for Persons with Disabilities: Contact Desiree Robinson at (360) 236-4107, TDD (1) 800 or (833) 6388.

Submit Written Comments to: Suzanne Shillander, Center for Health Statistics, P.O. Box 47814, Olympia, WA 98504-7814, fax (360) 753-4135, by September 10, 2002.

Date of Intended Adoption: September 11, 2002.

August 1, 2002

M. C. Selecky, Secretary

August 2, 2002

Don Sloma, Director

OTS-5810.1


NEW SECTION
WAC 246-491-001   Purpose.   RCW 70.58.055 requires certificates for vital records to include, at a minimum, items recommended by the federal agency responsible for national vital statistics. RCW 70.58.055 allows the state board of health to require additional information for the confidential section of the birth certificate, and eliminate items from the federal forms that it identifies as not necessary for statistical study.

RCW 43.70.150 requires the secretary of the department of health to operate and maintain a state system for registering births, deaths, fetal deaths, marriages, divorce decrees, annulments and separations. RCW 43.70.160 requires the state registrar to prepare, print and supply the forms for registering, recording, and preserving vital statistics. These rules identify the forms used and information collected by the state on live birth, death, fetal death, marriage, divorce, dissolution of marriage and annulment.

[]


NEW SECTION
WAC 246-491-010   Definitions.   The definitions in this section apply throughout this chapter unless the context clearly requires otherwise:

(1) "Board" means the state board of health.

(2) "Department" means the department of health.

[]


AMENDATORY SECTION(Amending Order 196B, filed 9/26/91, effective 10/27/91)

WAC 246-491-029   ((Adoption of)) Information collected on the confidential section of live birth and fetal death certificates; modifications to the United States standard certificates and report(( -- Modifications)) forms.   ((Pursuant to chapter 70.58 RCW, the Washington state board of health adopts and approves for use in the state of Washington,)) (1) Effective January 1, ((1992)) 2003, the department shall use the ((1988)) 2003 revisions of the United States standard forms of live birth and fetal death as the basis for the state certificates of live birth and fetal death. These forms are developed by the United States Department of Health and Human Services, National Center for Health Statistics. ((The board of health shall make the following modifications to the confidential section of the U.S. standard certificate of live birth and U.S. standard report of fetal death:))

(2) Copies of these forms may be obtained by contacting the department's center for vital statistics.

(3) Tables 1 and 2 list the statistical information contained in the confidential sections of the birth and fetal death certificates that the board requires the department to collect, and the differences between the state and U.S. standard.


((U.S. STANDARD CERTIFICATE OF LIVE BIRTH
Add "Spanish" to "of Hispanic origin."
Add "or descent? (ancestry)" to "of Hispanic origin."
Add "Asian or Pacific Islander" to "race."
Add "occupation" and "type of business or industry" for both parents.
Add "parental identification of ethnicity and race of child."
Add "twenty weeks or more, less than twenty weeks" to "pregnancy history."
Add separate categories for "spontaneous" and "induced" terminations to "pregnancy history."
Add "total prior pregnancies."
Add under the heading "medical risk factors for this pregnancy," "polyhydramnios, genital herpes, syphilis, "hepatitis B-HBsAg positive."
Add under the heading "method of delivery," "C-section with no labor, C-section with trial of labor."
Add under the heading "abnormal conditions of the newborn," drug withdrawal syndrome in newborn.
Delete under 38a "hydramnios."
Delete under item 37b "name of facility infant transferred to."
Add under the heading "other risk factors for pregnancy," "weight before pregnancy."
Add under the heading "complication of labor and/or delivery," "nuchal cord."
Change "tobacco use during pregnancy" to "did mother smoke at any time during pregnancy"?
Add "principal source of payment for prenatal care."
Add "during pregnancy mother participated in (special programs)."))

U.S. STANDARD CERTIFICATE OF LIVE BIRTH
TABLE 1:

Confidential Birth Certificate Items

Item Number Item Name Difference from U.S. Standard, if any
15 Is mother married to the father?
If no, was mother married to anyone during the pregnancy? Added
Has the paternity affidavit been signed?
20 Mother's education Add "Specify": next to box for "8th Grade or less"
21 Mother of Hispanic origin?
22 Mother's race
23 Mother's occupation Added
24 Mother's kind of business/industry Added
29 Father's education Add "Specify": next to box for "8th Grade or less"
30 Father of Hispanic origin?
31 Father's race
32 Father's occupation Added
33 Father's kind of business/industry Added
34 Mother's medical record number
35 Mother's prepregnancy weight
36 Mother's weight at delivery
37 Mother's height
38 Did mother get WIC food for herself during pregnancy?
39 Cigarette smoking before and during pregnancy
40a Number of previous live births
40b Date of last live birth
41a Number of other pregnancy outcomes
41b Date of last other pregnancy outcome
42a Date of first prenatal care visit
42b Date of last prenatal care visit
43 Total number of prenatal visits for this pregnancy
44 Date last normal menses began
45 Was mother transferred to higher-level care for maternal medical or fetal indications for delivery?
46 Principal source of payment for this delivery Add "Indian Health" and "CHAMPUS"
47 Newborn medical record number
48 Birth weight
49 Infant head circumference Added
50 Obstetric estimate of gestation
51 Apgar score at 5 min; if score is less than 6, score at 10 minutes
52 Plurality
53 If not single birth - born 1st, 2nd, 3rd etc.
54 Was infant transferred within 24 hours of delivery?
55 Is infant living at time of the report?
56 Is infant being breastfed?
57 Risk factors in this pregnancy Add "Group B streptococcus culture positive"
58 Method of delivery
59 Infections present and/or treated during this pregnancy Add "HIV infection" and "Other: Specify"
60 Obstetric procedures
61 Abnormal conditions of the newborn
62 Characteristics of labor and delivery
63 Congenital anomalies of the newborn
64 Maternal morbidity
65 Onset of labor

((U.S. STANDARD REPORT OF FETAL DEATH
Add "or descent? (ancestry)" to "of Hispanic origin."
Add "Spanish" to "of Hispanic origin."
Add "Asian or Pacific Islander" to "race."
Add "twenty weeks or more, less than twenty weeks" to "other pregnancy outcomes."
Add under the heading "medical risk factors for this pregnancy" "polyhydramnios, first trimester bleeding, epilepsy, genital herpes, syphilis."
Add separate categories for "spontaneous" and "induced" terminations to "pregnancy history."
Add "total prior pregnancies."
Add "fetal hemorrhage, placenta and cord conditions (specify), hemolytic disease, fetal hydrops, shoulder dystocia, other (specify), and none."
Add "C-section with no labor" and "C-section with trial of labor."
Add under the heading "other risk factors for pregnancy," "weight before pregnancy."
Change "tobacco use during pregnancy" to "did mother smoke at any time during pregnancy"?
Add "principal source of payment for prenatal care."
Add "during pregnancy mother participated in (special programs)."
Delete under item 23a "hydramnios and uterine bleeding."
Delete under item 26 "hysterotomy/hysterectomy."))

U.S. STANDARD REPORT OF FETAL DEATH
TABLE 2:

Confidential Fetal Death Certificate Items

Item Number Item Name Difference from U.S. Standard, if any
38 Weight of fetus
39 Obstetric estimate of gestation
40 Plurality
41 If not single birth - born 1st, 2nd, 3rd etc.
42 Mother's education Add "Specify": next to box for "8th Grade or less"
43 Mother of Hispanic origin?
44 Mother's race
45 Mother's occupation Added
46 Mother's kind of business/industry Added
47 Mother married?
48 Mother's height
49 Did mother get WIC food for herself during pregnancy?
50 Mother's prepregnancy weight
51 Mother's weight at delivery
52 Date last normal menses began
53 Date of first prenatal care visit
54 Date of last prenatal care visit
55 Total number of prenatal visits for this pregnancy
56a Number of previous live births
56b Date of last live birth
57a Number of other pregnancy outcomes
57b Date of last other pregnancy outcome
58 Cigarette smoking before and during pregnancy
59 Was mother transferred to higher-level care for maternal medical or fetal indications for delivery?
60 Father's education Added
61 Father of Hispanic origin? Added
62 Father's race Added
63 Father's occupation Added
64 Father's kind of business/industry Added
65 Risk factors in this pregnancy
66 Method of delivery
67 Congenital anomalies of the fetus
68 Maternal morbidity
69 Infections present and/or treated during this pregnancy Add "HIV infection" and "Other: Specify"

[Statutory Authority: Chapter 70.58 RCW. 91-20-073 (Order 196B), 246-491-029, filed 9/26/91, effective 10/27/91. Statutory Authority: RCW 43.20.050. 91-02-051 (Order 124B), recodified as 246-491-029, filed 12/27/90, effective 1/31/91. Statutory Authority: RCW 70.58.200. 88-19-092 (Order 310), 248-124-010, filed 9/20/88. Statutory Authority: RCW 43.20.050 and 70.58.200. 84-02-004 (Order 270), 248-124-010, filed 12/23/83; Order, 248-124-010, filed 9/1/67.]


AMENDATORY SECTION(Amending Order 196B, filed 9/26/91, effective 10/27/91)

WAC 246-491-039   Confidential information on state of Washington live birth and fetal death certificates ((pursuant to)) under chapter 70.58 RCW.   The confidential sections of the certificate of live birth and the certificate of fetal death ((shall)) are not ((be)) subject to public inspection and ((shall)) may not be included on certified copies of the record except upon order of a court.

[Statutory Authority: Chapter 70.58 RCW. 91-20-073 (Order 196B), 246-491-039, filed 9/26/91, effective 10/27/91. Statutory Authority: RCW 43.20.050. 91-02-051 (Order 124B), recodified as 246-491-039, filed 12/27/90, effective 1/31/91. Statutory Authority: RCW 70.58.200. 88-19-092 (Order 310), 248-124-015, filed 9/20/88.]


AMENDATORY SECTION(Amending Order 211, filed 11/12/91, effective 12/13/91)

WAC 246-491-149   ((Adoption of)) Information collected on the legal or public section of certificates; modifications to the United States standard certificates and report(( -- Modifications pursuant to RCW 43.70.150)) forms.   ((The department adopts and approves for use in the state of Washington,)) (1) Effective January 1, ((1992)) 2003, the department shall use the ((1988)) 2003 revisions of the United States standard forms for live birth((, death,)) and fetal death((, marriage, and dissolution)).

(2) Effective January 1, 2004, the department shall use the 2003 standard form for death.

(3) Effective January 1, 1992, the department shall use the 1988 revisions of the United States standard forms for marriage and dissolution.

(4) These forms are developed by the United States Department of Health and Human Services, National Center for Health Statistics. Copies of these forms may be obtained by contacting the department's center for vital statistics.

(5) With the exception of the confidential section, the department may modify any part of these forms ((and shall make the following modifications:)). Tables 3, 4, and 5 identify the modifications to the United States standard forms for live birth, fetal death, and death. Tables 6 and 7 identify modifications to the United States standard form for marriage, and certificate of divorce, dissolution of marriage, or annulment.


((U.S. STANDARD CERTIFICATE OF LIVE BIRTH.
Add "mother's request to issue Social Security number (allow up to six months)."
Add "record amendment."
Add "how long at current residence"?

U.S. STANDARD CERTIFICATE OF DEATH.
Under "place of death" add "in transport," "hospital."
Add "smoking in last fifteen years."
Add "or descent" after "of Hispanic origin."
Add "length of residence."
Add "date of disposition."
Add "medical examiner/coroner file number."
Add "hour pronounced dead (24-hours)."
Add "record amended section."
Delete "license number (funeral director)" under item 21b.
Delete "license number (certifier)" under item 23b.
Delete "were autopsy findings available prior to completion of cause of death yes/no" under item 28b.
Delete check boxes under item 20a.
Delete "donation" under item 20a.
Delete check boxes under item 31a.
Delete item 32.
Delete "inpatient" under item 9a.
Delete check boxes under item 29.
Delete "natural" under item 29.

U.S. STANDARD REPORT OF FETAL DEATH.
Add "fetus name."
Add "time of delivery."
Add "place of delivery."
Add "state of birth."
Add "registrar signature."
Add "date filed."
Add "burial, cremation, removal, other (specify)."
Add "date (burial)."
Add "cemetery/crematory-name."
Add "location (cemetery)."
Add "funeral director signature."
Add "name of facility."
Add "address of facility."
Add "autopsy yes/no."
Add "were autopsy findings used to complete the cause of death"?
Add "certification statement."
Change title to "certificate of fetal death."

U.S. STANDARD LICENSE AND CERTIFICATE OF MARRIAGE.
Change title to "certificate of marriage."
Add "type of ceremony (religious/civil ceremony)."
Add "officiant - date signed."
Add "inside of city limits for bride and groom."
Delete "age last birthday" for the groom under item 2.
Delete "age last birthday" for the bride under item 9.
Delete "license to marry" section.
Delete "expiration date of license" under item 17.
Delete "title of issuing official" under item 20.
Delete "confidential information" under items 27 through 30b.

U.S. STANDARD CERTIFICATE OF DIVORCE, DISSOLUTION OF MARRIAGE, OR ANNULMENT.
Change title to "certificate of dissolution, declaration of invalidity of marriage or legal separation."
Add check boxes for "type of decree."
Add "inside city limits" for both parties.
Delete "date couple last resided in same household" under item 11.
Change "number of children under eighteen in this household as of this date" to "number of children born alive of this marriage" under item 12.
Delete check boxes for "petitioner" under item 13.
Delete section "number of children under eighteen whose physical custody was awarded to" under item 18.
Delete "title of court" under item 20.
Delete "title of certifying official" under item 22.
Delete "date signed" under item 23.
Delete "confidential information" under items 24 through 27b.))

U.S. STANDARD CERTIFICATE OF LIVE BIRTH
Table 3:

Legal or Public Birth Certificate Items

Item Number Item Name Difference from U.S. Standard, if any
1 Child's name
2 Child's date of birth
3 Time of birth
4 Type of birthplace Add "En route"
5 Child's sex
6 Name of facility
7 City, town or location of birth
8 County of birth
9 Mother's name before first marriage
10 Mother's date of birth
11 Mother's birthplace
12 Mother's Social Security number
13 Mother's current legal last name
14 Social Security number requested for child?
16a Mother's residence - number, street, and Apt. No.
16b Mother's residence - city or town
16c Mother's residence - county
16d Tribal reservation name (if applicable) Added
16e Mother's residence - state or foreign country
16f Mother's residence - zip code + 4
16g Mother's residence - inside city limits?
17 Telephone number Added
18 How long at current residence? Added
19 Mother's mailing address, if different
25 Father's current legal name
26 Father's date of birth
27 Father's birthplace
28 Father's Social Security number
66 Certifier name and title Delete check boxes
67 Date certified
68 Attendant name and title Delete check boxes
69 NPI of person delivering the baby
--- Date filed by registrar Deleted

U.S. STANDARD REPORT OF FETAL DEATH
Table 4:

Legal or Public Fetal Death Certificate Items

Item Number Item Name Difference from U.S. Standard, if any
1 Name of fetus
2 Sex
3 Date of delivery
4 Time of delivery
5 Type of birthplace Add "En route"
6 Name of facility
7 Facility ID (NPI)
8 City, town or location of birth
9 Zip code of delivery
10 County of birth
11 Mother's name before first marriage
12 Mother's date of birth
13 Mother's current legal last name
14 Mother's birthplace
15a Mother's residence - number, street, and Apt. No.
15b Mother's residence - city or town
15c Mother's residence - county
15d Tribal reservation name (if applicable) Added
15e Mother's residence - state or foreign country
15f Mother's residence - zip code + 4
15g Mother's residence - inside city limits?
16 How long at current residence? Added
17 Father's current legal name
18 Father's date of birth
19 Father's birthplace
20 Name and title of person completing the report
21 Date report completed
22 Attendant name and title Delete check boxes
23 NPI of person delivering the baby
24 Method of disposition
25 Date of disposition
26 Place of disposition Added
27 Location of disposition - city/town and state Added
28 Name and complete address of funeral facility Added
29 Funeral director signature Added
30 Initiating cause/condition (cause of death)
31 Other significant causes or conditions
32 Estimated time of fetal death
33 Was an autopsy performed?
34 Was a histological placental examination performed?
35 Were autopsy or histological placental examination results used in determining the cause of death?
36 Registrar signature Added
37 Date received

U.S. STANDARD CERTIFICATE OF DEATH
Table 5:

Death Certificate Items

Item Number Item Name Difference from U.S. Standard, if any
1 Legal name (include a.k.a.'s if any)
2 Death date
3 Sex
4a Age - years
4b Age - under 1 year
4c Age - under 1 day
5 Social Security number
6 County of death
7 Birth date
8a Birth place - city, town or county
8b Birth place - state or foreign country
9 Decedent's education Add "Specify": next to box for "8th Grade or less"
10 Decedent's Hispanic origin
11 Decedent's race
12 Was decedent ever in U.S. Armed Forces?
13a Residence - number and street
13b Residence - city or town
13c Residence - county
13d Tribal reservation name (if applicable) Added
13e Residence - state or foreign country
13f Residence - zip code
13g Inside city limits?
14 Estimated length of time at residence Added
15 Marital status at time of death
16 Surviving spouse's name
17 Occupation
18 Kind of business/industry
19 Father's name
20 Mother's name before first marriage
21 Informant - name
22 Informant - relationship to decedent
23 Informant - address
24 Place of death
25 Facility name (if not a facility, give number and street)
26a City, town, or location of death
26b State of death
27 Zip code of death
28 Method of disposition
29 Place of disposition (name of cemetery, crematory, other place)
30 Disposition - city/town, and state
31 Name and complete address of funeral facility
32 Date of disposition Added
33 Funeral director signature
34 Causes of death and intervals between onset and death
35 Other significant conditions contributing to death
36 Autopsy?
37 Were autopsy findings available to complete the cause of death?
38 Manner of death
39 Pregnancy status
40 Did tobacco use contribute to death?
41 Date of injury
42 Hour of injury
43 Place of injury
44 Injury at work?
45 Injury location - street, city, county, state, zip County Added
46 Describe how injury occurred
47 Transport injury type
48a Certifying physician signature
48b Medical examiner/coroner signature
49 Name and address of certifier
50 Hour of death
51 Name and title of attending physician if other than certifier Added
52 Date certified
53 Title of certifier
54 License number of certifier
55 ME/coroner file number Added
56 Was case referred to medical examiner?
57 County registrar signature Added
58 County date received Added
59 Record amendment Added
-- License number of funeral director Deleted
-- Date pronounced dead Deleted
-- Time pronounced dead Deleted
-- Signature of person pronouncing death Deleted
-- License number of person pronouncing death Deleted
-- Date person pronouncing death signed Deleted

U.S. STANDARD LICENSE AND CERTIFICATE OF MARRIAGE
Table 6:

Certificate of Marriage

Item Number Item Name Difference from U.S. Standard, if any
-- Certificate name Changed name of form to "Certificate of Marriage”
-- County of license
-- Date valid
-- Not valid after (date)
1 Date of marriage
2 County of ceremony
3 Type of ceremony Added
4 Date signed (by officiant) Added
5 Officiant's name
6 Officiant's signature
7 Officiant's address
8 Groom's name
9 Groom's address (street)
10 Groom's date of birth
11 Groom's place of birth (state or country)
12 Groom's address (city)
13 Groom's address (inside city limits) Added
14 Groom's address (county)
15 Groom's address (state)
16 Groom's father - name
17 Groom's father - place of birth
18 Groom's mother - maiden name
19 Groom's mother - place of birth
20 Groom's signature
21 Date signed (by groom)
22 Bride's name
23 Bride's maiden last name
24 Bride's residence - (street)
25 Bride's date of birth
26 Bride's place of birth (state or country)
27 Bride's residence (city)
28 Bride's residence (inside city limits) Added
29 Bride's residence (county)
30 Bride's residence (state)
31 Bride's father - name
32 Bride's father - place of birth
33 Bride's mother - maiden name
34 Bride's mother - place of birth
35 Bride's signature
36 Date signed (by bride)
37 Witness #1 signature
38 Witness #2 signature
39 County auditor signature
40 Date received (by county auditor)
Reverse side Groom's Social Security number
Reverse side Bride's Social Security number
Groom's age last birthday Deleted
Bride's age last birthday Deleted
License to marry section Deleted
Expiration date of license Deleted
Title of issuing official Deleted
Confidential information Deleted

U.S. STANDARD CERTIFICATE OF DIVORCE, DISSOLUTION OF MARRIAGE, OR ANNULMENT
TABLE 7:

Certification of Dissolution, Declaration of Invalidity of Marriage, or Legal Separation

Item Number Item Name Difference from U.S. Standard, if any
Certificate name Changed form name to certificate of dissolution, declaration of invalidity of marriage or legal separation
Court file number
1 Type of decree Added check boxes
2 Date of filing
3 County where decree filed
4 Signature of superior court clerk
5 Husband's name
6 Husband's date of birth
7 Husband's place of birth
8 Husband's residence - street
9 Husband's residence - city
10 Husband's residence - inside city limits Added
11 Husband's residence - county
12 Husband's residence - state
13 Wife's name
14 Wife's maiden name
15 Wife's date of birth
16 Wife's place of birth
17 Wife's residence - street
18 Wife's residence - city
19 Wife's residence - inside city limits Added
20 Wife's residence - county
21 Wife's residence - state
22 Place of marriage - county
23 Place of marriage - state
24 Date of marriage
25 Number of children of this marriage Name change
26 Petitioner Delete check boxes
27 Name of petitioner's attorney/pro se
28 Petitioner's address
29 Husband's Social Security number
30 Wife's Social Security number
Date couple last resided in same household Delete
Number of children under 18 whose physical custody was awarded to Delete
Title of court Delete
Title of certifying official Delete
Date signed Delete
Confidential information Delete

[Statutory Authority: RCW 43.70.150. 91-23-026 (Order 211), 246-491-149, filed 11/12/91, effective 12/13/91. Statutory Authority: RCW 43.70.040. 91-02-049 (Order 121), recodified as 246-491-149, filed 12/27/90, effective 1/31/91. Statutory Authority: RCW 43.20A.620. 88-19-034 (Order 2696), 248-124-160, filed 9/12/88.]

Washington State Code Reviser's Office