3701-5-02 Forms used in the system of vital statistics.

 

 

 

3701-5-02                    Forms used in the system of vital statistics.

 

 

 

The following forms, as set forth in the designated appendices to this rule, are prescribed for use in the system of vital statistics. Notwithstanding the requirement that the forms set forth below be used in the system of vital statistics, a mother's name and address and a father's name are not required to be entered on a fetal death certificate.

 

(A)    The following forms, as set forth in the designated appendices to this rule, are prescribed for use in the system of vital statistics. Notwithstanding the requirement that the forms set forth below be used in the system of vital statistics, a mother's name and address and a father's name are not required to be entered on a fetal death certificate.Certificate of live birth (appendix A);

 

(1)Certificate of live birth (appendix A);

 

(2) Certificate of death (appendix B);

 

(3) Certificate of fetal death (appendix C);

 

(4) Provisional death certificate (appendix D);

 

(5) Supplementary medical information (appendix E);

 

(6) Certificate of service (appendix F);

 

(7) Burial-transit permit (appendix G);

 

(8) Certificate of adoption (appendix H);

 

(9) Affidavit requesting new birth certificate for adopted child (appendix I);

 

(10) Certified abstract of marriage (appendix J);

 

(11) Certified abstract of divorce, annulment, or dissolution (appendix K);

 

(12) Determination of paternity (appendix L);

 

(13) Affidavit for correction of birth, death or fetal death record (appendix M);

 

(14) Application, finding, and order for correction of birth record (appendix N);

 

(15) Supplemental report of given name of child (appendix O);

 

(16) Finding and order establishing registration of birth (appendix P);

 

(17) Application, finding, and order for registration (appendix Q);

 

(18) Affidavit for adopted person requesting information (appendix R);

 

 

(19) Authorization to release information about biological parent (appendix S);

(20) Authorization to release information about biological sibling (appendix T);

(21) Withdrawal  of  authority  to  release  information  about  biological  parent (appendix U);

(22) Withdrawal  of  authority  to  release  information  about  biological  sibling (appendix V);

(23) Disclosure statement for medical and health information (appendix W);

(24) Application for certified copy of birth or death certificate or paternity affidavit (appendix X);

(25) Application for certificate of public record (appendix Y);

(26) Denial of release for birth parent (appendix Z);

(27) Authorization for release form for birth parent (appendix AA);

(28) Request for assistance by adopted person (appendix BB);

(29) Rescission of request for assistance by adopted person (appendix CC);

(30) Certification of birth (appendix DD);

(31) Certification of death (appendix EE);

(32) Certification of stillbirth certificate (appendix FF);

(B) To be registered, each vital record that is required to be filed under Chapter 3705. of the Revised Code shall comply with all of the following requirements, except as otherwise provided in that chapter:

(1) The record shall be prepared in a form approved or prescribed and distributed by the director;

(2) The record shall be prepared and completed in accordance with the written instructions prescribed and distributed by the director;

(3) The record shall contain all items of information requested thereon. If any such items are omitted, the person responsible for completion of the record shall satisfactorily account for their omission;

(4) The record shall contain, in type or legible print, the certifier's name under his or her signature; and

(5) All signatures required on the record shall be handwritten in black ink or by an electronic signature.

(C) All forms, certificates, and reports used in the system of vital statistics are the property of the Ohio department of health and shall be surrendered to the state registrar upon demand. The forms prescribed and distributed by the director for reporting vital statistics shall be used only for official purposes. Only those forms furnished or approved by the director shall be used in the reporting of vital statistics or in making copies thereof.

(B)Birth registration card (appendix B);

(C)Foundling report (appendix C);

(D)Certificate of death (appendix D);

(E)Certificate of fetal death (appendix E);

(F) Provisional death certificate (appendix F);

(G)Supplementary medical information (appendix G);

(H)Certificate of service (appendix H);

(I)Burial-transit permit (appendix I);

(J) Burial permit record (appendix J);

(K)Certificate of Adoption (appendix K);

(L)Affidavit requesting new birth certificate for adopted child (appendix L);

(M) Certified abstract of marriage (appendix M);

(N)Certified abstract of divorce, annulment, or dissolution (appendix N);

(O)Declaration of Paternity (appendix O);

(P) Affidavit for correction of birth record (appendix P);

(Q)Affidavit for correction of death or fetal death record (appendix Q);

(R)Application, finding, and order for correction of birth record (appendix R);

(S) Supplemental report of given name of child (appendix S);

(T) Finding and order establishing registration of birth (appendix T);

(U)Application, finding, and order for registration of birth (appendix U);

(V)Affidavit for adopted person requesting information; (appendix V);

(W) Authorization to release information about biological parent (appendix W);

(X)Authorization to release information about biological sibling (appendix X);

(Y)Withdrawal of authority to release information about biological parent (appendix Y);

(Z)Withdrawal of authority to release information about biological sibling (appendix Z);

(AA) Disclosure statement for medical and health information (appendix AA);

(BB) Application for certified copy of birth certificate (appendix BB);

(CC) Application for birth registration card (appendix CC);

(DD) Application for certified copy of death certificate (appendix DD);

(EE) Application for certificate of public record (appendix EE);

(FF) Denial of release for birth parent (appendix FF);

(GG) Authorization of release form for birth parent (appendix GG);

(HH) Request for assistance by adopted person (appendix HH);

(II)          Rescission of request for assistance by adopted person (appendix II).

(JJ) To be registered, each vital record that is required to be filed under Chapter 3705. of the Revised Code shall comply with all of the following requirements, except as otherwise provided in that chapter:(

(1) The record shall be prepared on a form approved or prescribed and distributed by the director;

(2) The record shall be prepared and completed in accordance with the written instructions prescribed and distributed by the director;

(3) The record shall be an original certificate or abstract and shall not be a carbon copy or marked "copy" or "duplicate";

(4) The record shall contain all items of information requested thereon, which shall be entered onto the record in permanent black ink. If any such items are omitted, the person responsible for completion of the record shall satisfactorily account for their omission;

(5) The record shall contain, in type or legible print, the certifier's name under his or her signature; and

(6) All signatures required on the record shall be handwritten in black ink.

(KK) All forms, certificates, and reports used in the system of vital statistics are the property of the Ohio department of health and shall be surrendered to the state registrar upon demand. The forms prescribed and distributed by the director for reporting vital statistics shall be used only for official purposes. Only those forms furnished or approved by the director shall be used in the reporting of vital statistics or in making copies thereof.

Effective:   R.C. 119.032 review dates:	12/01/2005   08/30/2005 and 09/01/2010
CERTIFIED ELECTRONICALLY
Certification
11/07/2005
Date
Promulgated Under:	119.03
Statutory Authority:	3705.02, 3705.08
Rule Amplifies:	3705.08, 3107.45, 3107.47, 3107.48
Prior Effective Dates:	11/20/1994, 5/3/97