Current through Register Vol. 49, No. 9, September, 2024
AUTHORITY
The following Rules for Administration of Vital Records are
duly adopted and promulgated by the Arkansas State Board of Health pursuant to
the authority expressly conferred by the laws of the State of Arkansas, Act
1254 of 1995.
RULE 1.0. DUTIES OF
STATE REGISTRAR OF VITAL RECORDS
(Reference: Section 7 of Act 1254)
(a) The State Registrar, under the direction
of the State Board of Health, shall execute and enforce the provisions of the
laws and the Rules and supervise registrars, to the end that all of the
requirements shall be uniformly complied with. The Registrar shall have
authority to investigate cases of irregularity or violation of law, personally
or by accredited representative, and all local registrars and their deputies
shall aid the Registrar, upon request, in such investigations. The Registrar
shall report cases of violation of any of the provisions of the laws and rules
to the prosecuting attorney of the proper county, with a statement of facts and
circumstances.
(b) The State
Registrar shall have the authority to cross-reference birth and death
certificates on file for the same individual by stamping on the face
information necessary to show relation of the two certificates.
(c) Upon demand of the State Registrar in
person, mail, or through the local registrar, all physicians, coroners,
midwives, administrators in institutions, informants, nurse midwives, circuit
or county clerks, or funeral directors, and all other persons having knowledge
of the facts, shall furnish such information as they may possess regarding any
live birth, death, fetal death, marriage, divorce or annulment.
RULE 1.1 REGISTRATION DISTRICTS
The local county health unit in each county shall serve as
registration district for the deaths occurring in the county until notified
otherwise by the State Registrar. The Central Office shall serve as the site of
registration for births and fetal deaths. State Registrar may designate
additional offices.
RULE
1.2 FORMS
(Reference: Section 5(a)(5) of Act 1254 of 1995)
All forms, certificates and reports used in the system of vital
records are the property of the Board and shall be surrendered to the State
Registrar upon demand. The forms prescribed and distributed by the State
Registrar for reporting vital records shall be used only for official purposes.
No forms shall be used in the reporting of vital records or making copies
thereof, except those furnished or approved by the State Registrar. Electronic
data records will be accepted only when standards set by the State Registrar
are met.
RULE 1.3
REQUIREMENTS FOR PREPARATION OF CERTIFICATES
Legacy records refer to records which are issued from paper or
a digital image of a paper record. All legacy certificates and records relating
to vital records must either be prepared on a typewriter with a black ribbon or
printed legibly in black, unfading ink. All signatures required shall be
entered in black, unfading ink. Unless otherwise directed by the State
Registrar, no certificate shall be complete and correct and acceptable for
registration:
(a) That does not have
the certifier's name typed or printed legibly;
(b) That does not supply all items of
information called for thereon or satisfactorily account for their
omission;
(c) That contains
alterations or erasures;
(d) That
does not contain handwritten signatures as required;
(e) That is marked "copy" or
"duplicate";
(f) That is a carbon
copy;
(g) That is prepared on an
improper form;
(h) That contains
improper or inconsistent data;
(i)
That contains an indefinite cause of death which denotes only symptoms of
disease or conditions resulting from disease;
(j) That is not prepared in conformity with
rules or instructions issued by the State Registrar.
Electronic records refer to records which are issued from an
electronic database of information. All portions of the record that have been
prepared on paper must meet the same requirements as legacy records. Portions
of the record that have been entered directly into the database must:
(a) Contain all items of information called
for thereon or satisfactorily account for their omission;
(b) Must not contain an indefinite cause of
death which denotes only symptoms of disease or conditions resulting from
disease;
(c) Be attested to be
correct by a qualified funeral director or certifier who has personally
accessed the record with a previously assigned user identification and complex
password.
RULE
1.4 APPOINTMENT OF LOCAL REGISTRAR AND DEPUTY REGISTRARS
Each local registrar or deputy local registrar of vital records
shall be notified of his appointment or reappointment in writing, setting forth
the registration district and duties of his office.
The State Registrar shall appoint not less than one person to
be local registrar for deaths in each county. Each person so appointed shall
receive a written notice setting forth the area for which he or she is to be
responsible for promoting and supervising vital registration.
Each local registrar shall appoint and submit to the State
Registrar, the name of the person or persons who are to act as deputy local
registrars.
RULE 1.5
REMOVAL OF LOCAL REGISTRARS AND DEPUTY LOCAL REGISTRARS
Failure to carry out the provisions of the Vital Statistics Act
and rules adopted thereunder or conduct that may impair operation of the vital
records system shall be considered reasonable cause for removal of the local
registrar or deputy local registrar for vital records by the State Registrar.
Notification of such action shall be in writing.
RULE 2.0 DUTIES OF LOCAL REGISTRARS
(Reference: Section 7 of Act 1254 of 1995)
RULE 2.1 DUTIES
Each local registrar shall serve as the agent of the State
Registrar in his registration district and shall:
(a) Be familiar with Act 1254 of 1995, as it
pertains to birth, death and fetal death certificates;
(b) Maintain an adequate supply of all forms
and blanks furnished by the State Registrar and supply these to such persons as
require them;
(c) Examine legacy
certificates for accuracy and completeness as they are submitted for
registration to determine whether they have been prepared in accordance with
the Act, rules and instructions of the State Registrar;
(d) Notify the person responsible for the
filing when any certificate submitted for registration is unacceptable and
secure a complete and correct certificate;
(e) Sign each legacy certificate of death and
enter the date received by him/her and submit to the State Registrar;
(f) Issue certified copies of registered
death certificates within 24 hours of request. All forms and procedures used to
issue the copies shall be provided or approved by the State Registrar. If it is
deemed appropriate and feasible, local Registrar's office may be provided
access to all birth and/or death records filed in this State;
(g) Provide assistance to physicians,
hospitals, funeral homes and others in matters pertaining to vital
records;
(h) Perform such other
duties as required by the State Registrar.
RULE 2.2 ABSENCE, ILLNESS OR DISABILITY OF
THE LOCAL REGISTRAR
The local registrar shall notify the deputy local registrar of
his absence or incapacity to perform his duties. The deputy local registrar
shall thereupon immediately assume all duties and responsibilities of the local
registrar.
In case of any extended absence, the State Registrar shall be
notified in writing by the local registrar or deputy local registrar.
RULE 2.3 RESIGNATION OF LOCAL
REGISTRAR OR DEPUTY LOCAL REGISTRAR
A local registrar or a deputy local registrar shall submit his
resignation in writing to the State Registrar.
RULE 3.0 INFANTS OF UNKNOWN PARENTAGE;
FOUNDLING REGISTRATION
(Reference Section 19 of Act 1254 of 1995)
The report for an infant of unknown parentage shall be
registered on a regular certificate of live birth and shall:
(a) Have "foundling" plainly marked in the
top margin of the certificate;
(b)
Show the required facts as determined by approximation and have parentage data
left blank;
(c) Amend the
certification of the attendant to show the signature of the custodian and
indicate title, if any.
When a report has been sealed as provided by Section 19(d) of
the Vital Statistics Act, the State Registrar may inspect such information for
purposes of properly administering the vital records program.
RULE 4.0 BIRTH REGISTRATION
(Reference: Section 16 of Act 1254 of 1995)
RULE 4.1 OUT OF INSTITUTION BIRTH -
DOCUMENTARY EVIDENCE
When a birth occurs in this State outside of a hospital or
institution, and the birth certificate is filed before the first birthday,
additional evidence in support of the facts of birth may be required.
A certificate for the birth shall be completed and filed upon
presentation of the following evidence by the individual responsible for filing
the certificate:
(a) Evidence of
pregnancy, such as but not limited to:
(1)
Prenatal record, or
(2) A statement
from a physician or other health care provider qualified to determine
pregnancy, or
(3) a home visit by a
public health nurse or other health care provider, or
(4) other evidence acceptable to the State
Registrar.
(b) Evidence
that the infant was born alive, such as but not limited to:
(1) A statement from the physician or other
health care provider who saw or examined the infant, or
(2) an observation of the infant during a
home visit by a public health nurse, or
(3) other evidence acceptable to the State
Registrar.
(c) Evidence
of the mother's presence in this State on the date of birth, such as but not
limited to:
(1) If the birth occurred in the
mother's residence,
(a) a driver's license, or
a State-issued identification card, which includes the mother's current
residence on the face of the license/card, or
(b) a rent receipt that includes the mother's
name and address, or
(c) any type
of utility, telephone, or other bill that includes the mother's name and
address, or
(d) other evidence
acceptable to the State Registrar.
(2) If the birth occurred outside of the
mother's place of residence, and the mother is a resident of this State, such
evidence shall consist of:
(a) An affidavit
from the tenant of the premises where the birth occurred, that the mother was
present on those premises at the time of the birth, and
(b) evidence of the affiant's residence
similar to that required in paragraph (c)(1) of this rule, and
(c) evidence of the mother's residence in the
State similar to that required in paragraph (c)(1) of this rule, or
(d) Other evidence acceptable to the State
registrar.
(3) If the
mother is not a resident of this State, such evidence must consist of clear and
convincing evidence acceptable to the State Registrar. (See paragraph
(c)(2)).
RULE
4.2 DELAYED REGISTRATION OF BIRTH
(Reference: Section 17 of Act 1254 of 1995)
Certificates of birth filed after 10 days but within one year
from date of birth shall be registered on the standard live birth certificate
as prescribed in A.C.A. §
20-18-401.
Certificates of birth filed after one year but within four
years from the date of birth shall be registered on the standard live birth
certificate form in the manner prescribed in Section 16 of the Act. Such
certificates shall be marked "Delayed";
In any case where the certificate is signed by someone other
than the attendant or person in charge of the institution where the birth
occurred, a notarized statement setting forth the reason may be required by the
State Registrar. The State Registrar may require additional evidence in support
of the facts of birth and/or an explanation for the delay in filing.
RULE 4.3 DELAYED CERTIFICATE OF
BIRTH FORM
All certificates registered four years or more after the date
of birth are to be registered on a delayed certificate of birth form prescribed
by the State Registrar. A delayed birth certificate shall not be filed on a
deceased person.
RULE 4.4
WHO MAY REQUEST THE REGISTRATION OF AND SIGN A DELAYED CERTIFICATE OF BIRTH
Any person born in this State whose birth is not recorded in
this State, or his parent, guardian, next of kin, or older person age 28 years
or over acting for the registrant and having personal knowledge of the facts of
the birth may request the registration of a delayed certificate of birth,
subject to these rules and instructions issued by the State Registrar.
Each delayed certificate of birth shall be signed and sworn to
before an official authorized to administer oaths by the person whose birth is
to be registered if such person is age 18 years or over and is competent to
sign and swear to the accuracy of the facts stated therein; otherwise, the
certificate shall be signed and sworn to by one of the following in the
indicated order of priority:
(a) One
of the parents of the registrant, or
(b) The guardian of the registrant,
or
(c) The next of kin of the
registrant, or
(d) Any person 18
year or over having knowledge of the facts of birth.
RULE 4.5 FACTS TO BE ESTABLISHED FOR A
DELAYED REGISTRATION OF BIRTH
The minimum facts which must be established by documentary
evidence shall be the following:
(a)
The full name of the person at the time of birth;
(b) The date of birth and place of
birth;
(c) The full maiden name of
the mother;
(d) The full name of
the father; except that if the mother was not married to the father of the
child either at the time of conception or birth or any time between conception
and birth, the name "of the father shall not be entered on the delayed
certificate.
RULE 4.6
DELAYED REGISTRATION FOLLOWING A LEGAL CHANGE OF STATUS
When evidence is presented reflecting a legal change of status
by adoption, legitimation, paternity determination or acknowledgement, a new
delayed certificate may be established to reflect such changes. The existing
certificate and the evidence upon which the new certificate was based shall be
placed in a special file. Such file shall not be subject to inspection except
upon order of competent jurisdiction or by the State Registrar for purposes of
properly administering the vital records program.
RULE 4.7 DOCUMENTARY EVIDENCE - REQUIREMENTS
To be acceptable for filing, the name of the registrant at the
time of the birth and the date and place of birth entered on a delayed
certificate of birth shall be supported by at least:
(a) A hospital record created at the time of
birth, or two pieces of acceptable documentary evidence, if the record is filed
within 10 years after the date of birth, or;
(b) Three pieces of acceptable documentary
evidence, if the record is filed 10 years or more after the date of
birth.
RULE 4.8
DOCUMENTARY EVIDENCE - ACCEPTABILITY
The State Registrar shall determine the acceptability of all
documentary evidence submitted.
(a)
Documents presented, including but not limited to census, hospital, church, and
school records, must be from independent sources and shall be in the form of
the original record or a duly certified copy thereof or a signed statement from
the custodian of the record or document. Documents must have been established
at least one year prior to the date of application. Affidavits of personal
knowledge are not acceptable as evidence to establish a delayed certificate of
birth.
(b) All documents submitted
in evidence:
(1) for persons age 10 years or
over, must have been established at least 10 years prior to the date of
application, or within 3 years from the date of birth; and
(2) for persons under 10 years of age, must
be dated at least one year prior to the date of application or within the first
year of life.
RULE
4.9 ABSTRACTION OF DOCUMENTARY EVIDENCE
The State Registrar, or his or her designated representative,
shall abstract on the delayed certificate of birth a description of each
document submitted to support the facts shown on the delayed birth certificate.
This description shall include:
(a)
The title or description of the document;
(b) The name and address if the
custodian;
(c) The date of the
original filing of the document being abstracted and
(d) All birth facts required by Rule 4.5
contained in each document accepted as evidence.
All documents submitted in support of the delayed birth
registration shall be returned to the applicant after review.
RULE 4.10 CERTIFICATION BY THE
STATE REGISTRAR
The State Registrar, or his or her designated representative
shall verify:
(a) That no prior birth
certificate is on file for the person whose birth is to be recorded;
(b) That he or she has reviewed the evidence
submitted to establish the facts of birth; and
(c) That the abstract of the evidence
appearing on the delayed certificate of birth accurately reflects the nature
and content of the document.
RULE
4.11 DISMISSAL AFTER ONE YEAR
Applications for delayed certificates which have not been
completed within 1 year from the date of application may be dismissed at the
discretion of the State Registrar. Upon dismissal, the State Registrar shall so
advise the applicant and all documents submitted in support of such
registration shall be returned to the applicant.
RULE 5.0 NEW CERTIFICATES OF BIRTH FOLLOWING
LEGITIMATION, DETERMINATION OF PATERNITY, ACKNOWLEDGMENT OF PATERNITY,
ADOPTION, LEGAL CHANGE OF NAME.
(Reference: Section 20 and 21 of Act 1254 of 1995)
RULE 5.1 NEW CERTIFICATE
The new certificate of birth shall be on the form in use at the
time of its preparation and shall include the following items and such other
information necessary to complete the certificate:
(a) The name of the child;
(b) The date and place of birth as
transcribed from the original certificate;
(c) The names and personal particulars of the
adoptive parents or of the natural parents;
(d) The name of the attendant, printed or
typed;
(e) The same birth number as
was assigned to the original certificate;
(f) The original filing date.
The data necessary to locate the existing certificate and the
data necessary to complete the new certificate shall be submitted to the State
Registrar on forms prescribed or approved by him.
RULE 5.2 LEGITIMATION
If the natural parents marry after the birth of a child, a new
certificate of birth shall be prepared by the State Registrar for a child born
in this State, upon receipt of an affidavit of paternity signed by the natural
parent of said child, together with a certified copy of the parents' marriage
record. However, if another man is shown as the father of the child on the
original certificate, a new certificate may be prepared only when a
determination of paternity is made by a court of competent jurisdiction. The
new birth certificate shall not be marked "Amended".
RULE 5.3 DETERMINATION OF PATERNITY
A new certificate of birth shall be prepared by the State
Registrar for a child born in this State, upon receipt of a certified copy of a
court determination of paternity, together with a request from the natural
mother or person having legal custody of said child, that such new certificate
be prepared. If the surname of the child is not decreed by the court, the
request for the new certificate shall specify the surname to be placed on the
certificate. The new certificate shall not be marked "court order".
RULE 5.4 ACKNOWLEDGMENT OF
PATERNITY
A new certificate of birth shall be prepared by the State
Registrar for a child born out of wedlock in this State upon receipt of a sworn
acknowledgement of paternity signed by both parents and a written request by
both parents that the child's surname be changed on the certificate. However,
if another man is shown as the father of the child on the original certificate,
a new certificate may be prepared only when a determination of paternity is
made by a court of competent jurisdiction, or following adoption.
RULE 5.5 ADOPTION
(a) A new certificate of birth may be
prepared by the State Registrar for a child born in this State upon receipt of
an adoption report or certified copy of an adoption decree from the courts of
the several states of the United States or a foreign nation. The new birth
certificate shall not be marked "Amended".
(b) A certificate of birth shall be prepared
by the State Registrar for a child born in a foreign country and subsequently
adopted through a court of competent jurisdiction in Arkansas. An adoption
report as provided for in code
20-18-405
and a request that such a certificate be established, shall be submitted to the
State Registrar for preparation of an Arkansas certificate of foreign birth.
Such certificate shall not confer citizenship upon the child or the adoptive
parents.
RULE 5.6 LEGAL
CHANGE OF NAME
A new certificate of birth, following a legal name change,
shall be established upon receipt of a court order from a court of competent
jurisdiction.
This certificate shall be marked "Court Order".
RULE 5.7 EXISTING CERTIFICATE TO
BE PLACED IN A SPECIAL FILE
After preparation of the new certificate, the existing
certificate and the evidence upon which the new certificate was based are to be
placed in a special file.
Such file shall not be subject to inspection except upon order
of a court of competent jurisdiction or by the State Registrar for purposes of
properly administering the vital statistics program.
RULE 6.0 DEATH REGISTRATION
(Reference: Section 14 and 25 of Act 1254 of 1995 and Section 1
of Act 975 of 2019)
The funeral director shall electronically (or by system
designated by the State Registrar) file a fact of death within three days of
death. This shall consist of the legal name, date and time of death, county of
death, date of birth, Social Security Number, and resident address of the
deceased. Medical certification shall be completed and returned to the funeral
home electronically (or by a system designated by the State Registrar) within
three business days after receipt of the death certificate by the medical
certifier except when inquiry is required by§
12-12-315, §
12-12-318,
or §
14-15-301 et seq. The complete certificate shall be filed within ten
days. The funeral director is to notify the local county registrar of death
certificates that cannot be filed within ten (10) days.
RULE 6.1 ACCEPTANCE OF INCOMPLETE DEATH
CERTIFICATE
(a) If the attending physician,
medical examiner, or coroner are unable to complete the medical certification
of cause of death within the prescribed statutory time period, he may indicate
that cause of death is "pending" and sign the certification.
A supplemental report providing the medical information omitted
from the original certificate shall be filed by the certifier with the State
Registrar within (90) days.
The supplemental report(s) shall be made a part of the existing
death certificate. Supplemental reports filed after 90 days shall be considered
an application to amend the record. The certificate shall be marked
amended.
(b) If the funeral
home is unable to obtain the personal information about the deceased within the
prescribed statutory time period, the funeral director shall file a death
certificate form completed with all available information. If information is
unavailable, indicate "unknown". Within ten (10) days after the State Registrar
receives the certificate, the funeral director may make changes to personal
information where the change corrects an error made in the registration and
filing of the certificate. Do not mark "amended".
Amendment of errors to personal information or addition of
missing information made 10 days after receipt of the original certificate
shall be by affidavit and the certificate shall be marked "amended".
The State Registrar may make administrative corrections to
certificates within one year without certificate being marked "amended".
(c) In any case where an autopsy
is scheduled and the physician, coroner or medical examiner wishes to await its
gross findings to confirm a tentative clinical finding, he shall give the
funeral director notice as to when he expects to have the medical data
necessary for the certification of cause of death. If the provisions of Section
25 of Act 1254 of 1995 cannot be adhered to, he shall indicate that the cause
is "pending" and sign the certification. Immediately after the medical data
necessary for determining the cause of death have been made known, the
physician or coroner or medical examiner shall, over his signature, forward the
cause of death to the registrar on a form prescribed for that purpose by the
State Registrar.
RULE
6.2 COMPLETION OF CERTIFICATE WHEN DEATH OCCURS IN AN INSTITUTION
(a) When a death occurs in a hospital or
other institution and the death is not under the jurisdiction of the medical
examiner or coroner, the person in charge of such institution, or his or her
designated representative, shall be responsible for obtaining the medical
certificate. (This responsibility does not include DOA in the hospital
emergency room.)
(b) Hospitals or
other institutions may assist in preparation of the certificates by completing
the following items:
(1) Name of
deceased
(2) Date of
death
(3) Place of death
RULE 7.0 AUTHORIZATION
OF FINAL DISPOSITION
(Reference: Section 28 of Act 1254 of 1995)
RULE 7.1 BURIAL-TRANSIT PERMIT
(a) A burial-transit permit shall be required
when a dead body is cremated or transported out of the State.
(b) The burial-transit permit shall be issued
by the State Registrar and/or designated representative of the district in
which the death occurred upon request of a funeral director or his designated
representative.
(c) A
burial-transit permit may be waived for disposition in Arkansas for persons who
died in Arkansas and will be buried in Arkansas.
(d) Cremation shall occur as authorized by
the Arkansas State Board of Embalmers and Funeral Directors.
RULE 7.2 REMOVAL OF BODY
Before removing a dead body or fetus that has reached a
gestation period of 20 completed weeks, from the place of death, the funeral
director or his designated representative shall:
(a) Obtain assurance from the attending
physician that death is from natural causes and that the physician will assume
responsibility for certifying to the cause of death or fetal death;
or
(b) Contact the medical examiner
or coroner if the case comes within his jurisdiction and receive authorization
from him to remove the body.
RULE
7.3 DISPOSITION OF DEAD BODIES OR FETUSES
(a) Disposition of dead bodies or fetuses
shall be by burial in registered cemetery, or by cremation. Hospitals may
dispose of dead fetuses by incineration.
(b) The death and fetal death certificates
shall be certified by the physician, coroner, or Medical Examiner before
cremation or hospital disposal takes place.
(c) Dead bodies or fetuses may be donated to
the medical schools for research purposes.
RULE 7.4 DISINTERMENT
No dead human body shall be removed from its place of original
interment except under the following conditions:
(1) Unless a permit from the State Registrar
or his designated representative marked "Disinterment Permit" be secured by a
licensed funeral director in charge of the disinterment.
The qualified person making the application shall present to
the State Registrar, the correct name, age, date of death of the body to be
disinterred, place of disinterment, together with written consent of the next
of kin or their authorized representative, by the local law enforcement
officer, or by court order. The State Registrar may require legal proof of such
kinship or legal authority.
(2) All disinterment permits shall be void
after the expiration of thirty (30) days after the date of issue. An extension
of 30 days may be granted upon written request by the funeral
director.
(3) Procedures:
(a) The disinterment and removal must be
under the direction of a licensed funeral director and in accordance with the
rules governing the transportation of the dead. The coroner of the county of
burial must be notified of a disinterment.
(b) The casket in which a disinterred body is
contained shall not be opened at any time, except by court order, or under
instructions of the medical examiner or coroner of the county of
death.
(c) The funeral director
authorized to conduct a disinterment shall be held personally responsible for
the enforcement of these requirements.
(d) Upon receipt of court order or signed
permission of the next of kin, the State Registrar may issue one permit to
authorize disinterment and reinterment of all remains in a mass disinterment
provided that insofar as possible the remains of each body be identified and
the place of disinterment and reinterment specified.
(e) A dead body properly prepared by an
embalmer and deposited in a receiving vault shall not be considered a
disinterment when removed from the vault for final disposition.
RULE 8.0 TRANSPORTATION
OF DEAD BODIES
(Reference: Section 28 of Act 1254 of 1995)
(a) A transportation company shall accept a
dead human body for shipment only when it is accompanied by a properly
completed burial-transit permit.
(b) A transportation company shall not accept
a dead human body for shipment when fluid or offensive odors are escaping from
the case.
(c) A dead human body
transported by common carrier must be embalmed thoroughly by an approved
embalming process, placed in a rigid container made for the purpose, equipped
with sufficient handles on sides and ends. A body which cannot be embalmed, or
is in a state of decomposition, shall be transported only after enclosure in an
air-tight container.
RULE
8.1 PRESERVATION OF BODIES
All dead human bodies not buried within 24 hours after death
shall be embalmed in a manner approved by the Arkansas Board of Embalmers and
Funeral Directors, or stored under refrigeration at 45 degrees Fahrenheit or
less. When a dead body is being cremated, embalming and refrigeration shall not
be required for a forty-eight hour period after death unless a health problem
dictates otherwise.
RULE
8.2 BODIES PLACED IN VAULTS
Bodies placed in receiving vaults fifteen (15) days or more
shall be encased in an airtight container.
RULE 8.3 RESPONSIBILITY FOR THE
IDENTIFICATION OF THE BODY OF DECEASED PERSON WHO MAY HAVE BEEN INFECTED BY A
COMMUNICABLE DISEASE
See Rule XII of the Rules Pertaining to Reportable
Disease.
RULE 8.4 ACTS
TENDING TO PROMOTE SPREAD OF DISEASE PROHIBITED
Any physician or hospital caring for an individual who dies of
a contagious disease shall notify the funeral director on the death
certificate, or by other written notice, of the danger involved before the
funeral director takes possession of the body.
RULE 9.0 RECORDS AND REPORTS
(Reference: Section 9 of Act 1254 of 1995)
Each funeral director shall keep a record containing, as a
minimum, the following information about each dead body or fetus he
handles:
(a) The date, place, and time
of receipt;
(b) the date, place,
and manner of disposition;
(c) if
the dead body or fetus is delivered to another funeral director, the date of
such delivery and the name and address of the funeral director to whom
delivered; and
(d) the items
required by the certificate of death for those deaths for which the funeral
director was required to file the certificate.
RULE 10.0 DELAYED REGISTRATION OF DEATH
(Reference: Section 26 of Act 1254 of 1995)
RULE 10.1 REGISTRATION - ONE YEAR TO FOUR
YEARS
Certificates of death filed after one year, but within four
years from the date of death shall be registered on the standard certificate of
death form in the manner prescribed in Section 25 of Act 1254 of 1995. This
certificate shall be marked "Delayed".
When the physician, coroner, medical examiner or funeral
director is not available, Rule 10.1(d) shall be applicable.
(a) Delayed Certificate of Death Form
All certificates registered four years or more after the date
of death are to be registered on a delayed certificate of death form prescribed
by the State Registrar.
(b)
Who May Request a Delayed Certificate
Only the funeral director or the family of a person who died in
the State of Arkansas, whose death is not recorded, may file a delayed
certificate of death, subject to the procedures and requirements established by
these Rules and instructions issued by the State Registrar.
(c) When the Attending Physician, Coroner or
Medical Examiner and the Attending Funeral Director are Available
In cases where the attending physician, coroner or medical
examiner and the attending funeral director, or the funeral director that has
the deceased's records, are available to complete and sign the certificate, a
certificate may be completed without additional evidence and mailed directly to
the State Division of Vital Records. The State Registrar may request an
affidavit to substantiate the death certificate.
(d) When the Attending Physician, Coroner or
Medical Examiner and/or the Attending Funeral Director are Not Available
In cases where the attending physician, coroner or medical
examiner and/or the attending funeral director are not available to complete
and sign the certificate, the person applying to file a certificate shall
submit at least two documents, subject to the discretion of the State
Registrar, to establish that:
(1) The
person at one time did exist
(2)
The death did occur at the time and place so stated.
The certificate filed shall contain only such information as
can be proved by documentary evidence.
(e) Abstract on Delayed Death Certificates
If an application is acceptable for filing, the State Registrar
shall abstract on the delayed death certificate form a description of each
document submitted in support of the death registration, including the title or
description of the document, the name of the affiant if the document is an
affidavit of personal knowledge; or the name of the issuing organization if the
document is an original or certified copy of a record or a signed statement
taken from a document, and the date.
(f) Date of Filing and Departmental
Certification
The State Registrar then shall enter the date of filing and by
his signature thereto shall certify:
(1) That no prior death certificate is on
file for the person whose death is to be recorded.
(2) That he has reviewed the evidence
submitted to establish the facts of death.
(3) That the summary or abstract of the
evidence appearing on the delayed death certificate accurately reflects the
nature and character of the document.
RULE 11.0 REGISTRATION OF SPONTANEOUS FETAL
DEATHS (STILLBIRTH)
(Reference: Section 2 of Act 168 of 2017)
Each spontaneous fetal death where the fetus completed twelve
weeks gestation or more, calculated from the date of the last normal menstrual
period began to the date of delivery, that occurs in this State shall be
reported within five days after delivery to the State Registrar. The fetal
death shall be reported on a certificate furnished by the State
Registrar.
RULE 11.1
RESPONSIBILITY FOR REPORTING SPONTANEOUS FETAL DEATHS (STILLBIRTHS)
(a) When a spontaneous fetal death occurs
without medical attendance at/or immediately after the delivery, the medical
examiner or coroner shall investigate the cause of fetal death and shall
prepare and file the report within five (5) days.
(b) If the delivery of a dead fetus occurred
on a moving conveyance, the place of delivery shall be entered in accordance
with the instructions given for live births.
(c) The name of the father and other
information about the father shall be entered in accordance with instructions
given for live births.
(d) In the
case of multiple births, a separate report shall be submitted for each
fetus.
RULE 12.0 REPORT
OF INDUCED TERMINATION OF PREGNANCY
(Reference: Section 27 of Act 1254 of 1995)
(a) Induced terminations of pregnancy are to
be reported on Vital Records form VR-29, which is attached hereto as Appendix A
pursuant to Act 171 2013. Reports of induced termination of pregnancy are
statistical reports only and are not to be incorporated into the official
records of the Office of Vital Records.
(b) These are to be forwarded directly to the
Center for Health Statistics by the institution or by the physician in
attendance if pregnancy termination did not occur in a hospital. The Director
of the Center for Health Statistics is authorized to dispose of such reports
when all statistical processing of the records has been accomplished. However,
the Director of the Center for Health Statistics may establish a file of such
records so they will be available for future statistical and research projects
provided such a file is not made a part of the official records and the reports
are not made available for the issuance of certified copies.
(c) Such file shall be retained for as long
as the Director of the Center for Health Statistics deems necessary and it
shall then be destroyed. The file may be maintained by photographic,
electronic, or other means as determined by the Director of Health Statistics.
When such a file is established by the Director of the Center for Health
Statistics, the original reports from which they were made shall be
destroyed.
(d) A physician who
performs an abortion shall report monthly to the Center of Health Statistics
the number of informed consent certifications received pursuant to Act 1086 of
2015.
RULE 12.1 REPORT
OF SPONTANEOUS FETAL DEATH, (MISCARRIAGES) OF LESS THAN 12 WEEKS
(a) Each spontaneous fetal death or
miscarriage of less than 12 weeks gestation, as computed in Rule 11.0, is to be
reported on Vital Records form VR-28. These are statistical reports only and
are not to be incorporated into the official records of the Office of Vital
Records.
(b) These are to be
forwarded directly to the Center for Health Statistics by the institution or by
the physician in attendance if pregnancy termination did not occur in a
hospital. The Director of the Center for Health Statistics is authorized to
dispose of such reports when all statistical processing of the records has been
accomplished. However, the Director of the Center for Health Statistics may
establish a file of such records so they will be available for future
statistical and research projects provided such a file is not made a part of
the official records and the reports are not made available for the issuance of
certified copies.
(c) Such file
shall be retained for as long as the Director of the Center for Health
Statistics deems necessary and it shall then be destroyed. The file may be
maintained by photographic, electronic, or other means as determined by the
Director of Health Statistics. When such a file is established by the Director
of the Center for Health Statistics, the original reports from which they were
made shall be destroyed.
RULE
13.0 DELAYED REGISTRATION OF MARRIAGE
(Reference: Section 23 of Act 1254 of 1995)
(a) The registration of a marriage after one
year shall be registered on the report of marriage form.
(b) The marriage certificate must be filed
with the State Registrar by the county clerk where the marriage license was
originally issued. This certificate shall be marked "Delayed".
(c) In all cases, the State Registrar may
require additional evidence to prove the facts of marriage. RULE 14.0 AMENDMENT
OF VITAL RECORDS
(Reference: Section 14 of Act 1254 of 1995)
RULE 14.1 AMENDMENT OF MINOR
ERRORS ON BIRTH CERTIFICATES DURING THE FIRST YEAR
Amendment of obvious errors, transposition of letters in words
of common knowledge, or omissions on birth certificates may be made within the
first year after the date of birth upon request of persons defined in Rule
14.2. When such additions or minor amendments are made by the State Registrar,
an affidavit attesting to the true facts shall be attached to the certificate
in such a way as not to become a part of any certification issued. The
certificate is not to be marked "Amended".
RULE 14.2 AMENDMENT OF REGISTRANT'S GIVEN
NAMES ON BIRTH CERTIFICATES WITHIN THE FIRST YEAR
Until the registrant's first birthday, given names may be
amended upon written request of:
(a)
Both parents, or
(b) The mother in
the case of a child born out of wedlock, or
(c) The father in the case of the death or
incapacity of the mother, or
(d)
The mother in the case of the death or incapacity of the father, or
(e) The guardian or agency having legal
custody of the registrant.
After one year from the date of birth, the provisions of Rule
14.4 must be followed to amend a given name if the name was entered incorrectly
on the birth certificate. A legal change of name order must be submitted from a
court of competent jurisdiction to change a given name after one year.
RULE 14.3 ADDITION OF
GIVEN NAMES
After registrant's first birthday, given names for a child
whose birth was recorded without given names may be added to the certificate
upon written request of:
(a)
Registrant, if of legal age
(b)
Both parents, or
(c) The mother in
the case of a child born out of wedlock, or
(d) The father in the case of the death or
incapacity of the mother, or
(e)
The mother in the case of the death or incapacity of the father, or
(f) The guardian or agency having legal
custody of the registrant.
A certificate amended in this manner prior to the first
birthday is not to be marked "Amended".
After the first birthday, one of more items of documentary
evidence must be submitted to substantiate the name being added. This
certificate shall be marked "Amended".
RULE 14.4 ALL OTHER AMENDMENTS
Unless otherwise provided in these rules or in Section 14 of
Act 1254 of 1995, all other amendments to vital records shall be supported
by:
(a) An affidavit setting forth:
(1) Information to identify the
certificate;
(2) The incorrect data
as it is listed on the certificate;
(3) The correct data as it should
appear
(b) One or more
items of documentary evidence which support the alleged facts and which were
established at least five years prior to the date of application for amendment
or within seven years of the date of the event. Exceptions can only be made at
the discretion of the State Registrar.
The State Registrar shall evaluate the evidence submitted in
support of any amendment, and when he finds reason to doubt its validity of
adequacy, he may reject the amendment and shall advise the application of the
reasons for this action.
RULE
14.5 WHO MAY APPLY
(a) To amend a
birth certificate, application may be made by one of the parents if the
registrant is under age 18, the guardian, the registrant if he or she is age 18
years or over, or the individual responsible for filing the
certificate.
(b) To amend a death
certificate, application may be made by the next of kin, the informant listed
on the death certificate, or the funeral director or person acting as such who
submitted the death certificate. Applications to amend the medical
certification of cause of death shall be made only by the physician, coroner or
medical examiner who provided the medical certification. The report shall be
notarized unless submitted by an approved electronic process.
A court order shall be required to change marital status on
death certificates except when persons responsible for the completion of the
item make an error.
(c) To
amend a fetal death certificate, such application shall be made by one of the
parents. Amendments to the medical certification shall be made by the attending
physician, the medical examiner or the coroner. The funeral director shall
request any amendment to the date, place and method of disposal.
(d) Applications for amendment of
certificates of marriage shall be made jointly by both parties to the marriage
or by the survivor. In the event the marriage to which the application relates
was terminated by divorce, dissolution of marriage, or annulment on or before
the date of application for amendment, the applicant may request amendment only
of those items on the certificate of marriage which relate to the
applicant.
(e) Applications for
amendment of matters contained in certificates of divorce, dissolution of
marriage, or annulment which are not part of the decree or court order may be
made by either party to the marriage so terminated. Applications for amendment
of matters contained in certificates of divorce, dissolution of marriage, or
annulment which are part of the decree or court order may only be made by the
court which ordered the divorce, dissolution of marriage, or annulment upon
which the report was made.
RULE
14.6 AMENDMENT OF THE SAME ITEM MORE THAN ONCE
Once an amendment of an item is made on a vital record, that
item shall not be amended again unless a court order is received from a court
of competent jurisdiction. (New items on the certificate can be corrected with
a new affidavit and satisfactory proof.)
RULE 14.7 METHODS OF AMENDING CERTIFICATES
Certificates of birth, death, fetal death, marriage and divorce
may be amended by the State Registrar in the following manner:
(a) Completing the item in any case where the
item was left blank on the existing certificate.
(b) Legacy records, as previously defined,
shall be amended by drawing a single line through the item to be amended that
does not obliterate the original entry and inserting the correct data
immediately above or to the side thereof Electronic records shall be amended by
replacing incorrect information with correct information and adding a footnote
mark indicating that original information has been placed at the bottom of the
certificate.
(c) Completing a
special form for attachment to the original record. Such form shall include the
incorrect information as it appears on the original certificate, the correct
information as it should appear, an abstract of the documentation used to
support the amendment and sufficient information about the registrant to link
the special form to the original record. When a copy of the original record is
issued, a copy of the affidavit must be attached.
(d) A substitute certificate shall be
established with correction(s) as specified by the court and the original
certificate shall be removed to a special file.
(e) Items on delayed certificates that were
placed on a certificate as a result of documentary evidence can only be amended
by a court order.
(f) A certificate
of birth amended pursuant to the provisions of Section 14(d) of Act 1254 of
1995 shall be amended by preparing a new certificate. The item numbers of the
entries that were amended shall not, however, be identified on the new
certificate or on any certified copies that may be issued of that certificate.
Amended certificates shall be marked "Amended" as required by
Section 14 of Act 1254 of 1995, and the date the amendment was made, as well as
the initials of the person making the change shall be entered on the face of
the certificate. The affidavit and the summary of evidence shall be filed
following the amended certificate.
RULE 15.0 DISCLOSURE OF RECORDS
(Reference: Sections 2, 11 and 12 of Act 1254 and Section 2 of
Act 1295 of 1995)
To protect the integrity of vital records:
(a) The State Registrar shall not permit
inspection of, or disclose information contained in, vital statistics records,
or copy or issue a copy of all or part of any such record unless he or she is
satisfied that the applicant is authorized to obtain a copy or abstract of such
record.
(1) Family members doing genealogical
research and genealogists representing a family member may obtain copies of
records needed for their research. Unless the registrant is deceased,
appropriate authorizations shall be required from the registrant or relevant
family members as defined in Section 12 for the release of records.
(Grandparents and grandchildren are relevant family members.)
(2) The term "authorized representative"
shall include an attorney, physician, funeral director, or other authorized
agent acting in behalf of the registrant or his or her family.
(3) The natural parents of adopted children,
when neither has custody, and commercial firms or agencies requesting listings
of names and addresses shall not be authorized to obtain copies or abstracts of
the record.
(b) All
requests for disclosure of information contain in vital records or reports for
research which identifies any person or institution shall be submitted in
writing to the State Registrar.
(1) Each
request must contain:
(a) Objectives of the
research;
(b) peer review and
approval of study protocol for any contact of study subjects;
(c) storage and security measures to be taken
to assure confidentiality of identifying information, and provision for return
or destruction of the information at the conclusion of the research;
(d) time frame of the study;
(e) acknowledgement and agreement that
ownership of all information provided by the State Registrar shall remain
exclusively in the State Agency and that use of that information by the
researcher constitutes a license only for usage during the course of the
research and creates no ownership rights by the researcher; and
(f) acknowledgment and agreement that release
of identifying information contained in vital records or reports by the
researcher to any other person or entity may be made only with prior written
approval of the State Registrar.
(2) All requests shall be reviewed to
determine compliance with the following:
(a)
The request contains all required elements;
(b) the request adequately justifies the need
for the requested information;
(c)
the requested information can be provided within the time frame set forth in
the request; and
(d) the State
Agency has adequate resources with which to comply with the request;
(3) The State Registrar shall
enter into research agreements for all approved research requests. Each
research agreement shall specify exactly what information will be disclosed and
shall prohibit release by the researcher of any information which may identify
any person or institution. Additionally, each research agreement may provide
that in the event of breach the principal investigator(s) and collaborator(s)
shall be barred from participation in future research agreements and shall pay
to the State Agency the sum of ($5,000) per violation of the research
agreement.
(c) For all
requests for disclosure of information contained in vital records or reports
for research which does not contain identifiers but may identify any person or
institution, a signed agreement form must be obtained from the person or entity
requesting the information which provides the following assurances:
(1) The recipient will neither use nor permit
others to use the information in any way except for statistical reporting and
analysis;
(2) the recipient will
neither release nor permit others to release the information or any part of the
information to any person who is not a member of the organization without
approval of the State Registrar.
(3) the recipient will neither attempt to
link nor permit others to attempt to link the data set with individually
identifiable records from any other data set;
(4) the recipient will neither use nor will
allow anyone else to attempt to use the information to learn the identify of
any person or institution included in the information provided; and
(5) if the identity of any person or
institution is discovered inadvertently, the recipient will not make use of
this knowledge; will immediately notify the State Registrar; will safeguard or
destroy the information which led to the identification of the individual or
institution as requested by the State Registrar; and will inform no one else of
the discovery.
(d) The
State Registrar shall not issue a certified copy of a record until the
applicant has provided sufficient information to locate the record. Whenever,
it shall be deemed necessary to establish an applicant's right to information
from a vital record, the State Registrar shall also require identification of
the applicant or a sworn statement.
(e) When 100 years have elapsed after the
date of birth, or 50 years have elapsed after the date of death, marriage, or
divorce, dissolution of marriage, or annulment, such records in the custody of
the State Registrar shall become available to any person upon submission of an
application containing sufficient information to locate the record. For each
copy issued or search of the files made, the State Registrar shall collect the
same fee as is charged for the issuance of certified copies or a search of the
files for other records in his or her possession.
RULE 16.0 RECORD PRESERVATION
(Reference: Section 15 of Act 1254 of 1995)
When an authorized reproduction of a vital record has been
properly prepared by the State Registrar and when all steps have been taken to
ensure the continued preservation of the information, the record from which
such authorized reproduction was made may be disposed of by the State
Registrar. Such record may not be disposed of, however, until the quality of
the authorized reproduction has been tested to ensure that acceptable certified
copies can be issued and until a security copy of such document has been placed
in a secure location removed from the building where the authorized
reproduction is housed. Such security copy shall be maintained in such a manner
to ensure that it can replace the authorized reproduction should the authorized
reproduction be lost or destroyed.
RULE
17.0 COPIES OF DATA FROM VITAL RECORDS
(Reference: Section 12 of Act 1254 of 1995)
(a) Full certified copies or birth card
certification of vital records may be made by mechanical, electronic, or other
reproductive processes, except that the information contained in the
"Information for Medical and Health Use Only" section of live birth
certificates shall not be included.
(b) When a certified copy is issued, each
certification shall be signed and certified as a true copy by the State
Registrar in whose custody the record is entrusted and shall include the
certificate number, date issued, the registrar's signature or an authorized
facsimile thereof, and the seal of the issuing office shall be affixed
thereon.
(c) Confidential
verifications of the facts contained in vital records may be furnished by the
State Registrar to any federal, state, county or municipal government agency or
to any other agency representing the interest of the registrant, subject to the
limitations as indicated in (a) above. Such confidential verifications may be
on forms prescribed and furnished by the requesting agency and acceptable to
the State Registrar; or, the State Registrar may authorize the verification in
other ways when it shall prove in the best interest of his office.
(d) The State Registrar may authorize
certifier and originator to make a uncertified copy of a vital record for their
files only. No reproductions are to be issued from this copy for any
purpose.
(e) All certified copies
shall include, at a minimum, the following security features:
(1) sensitized security paper;
(2) background security design;
(3) copy void pantograph;
(4) consecutive numbering;
RULE 18.0 FEES FOR
COPIES AND SEARCHES
(Reference: Section 29 of Act 1254 of 1995)
(a) No certified copies shall be issued until
the fee for such copy is received unless specific approval has been obtained
from the State Registrar or otherwise provided for by the Act or Rules. Fees
shall be as specified in Arkansas Code
20-7-123.
(b) For research and statistical purposes the
State Registrar or the Director of Health Statistics shall determine the fee
for such services and determine the manner in which such cost shall be
paid.
(c) The State Registrar shall
determine the extent and the fees required to conduct an extensive record
search for a birth, death, fetal death, marriage or divorce record when
sufficient information cannot be provided by the applicant for a normal
search.
RULE 19.0
PERSONS REQUIRED TO KEEP RECORDS AND FILE REPORTS
(Reference: Section 9 of Act 1254 of 1995)
Each person in charge of any hospital or funeral home shall,
upon request, notify the State or local Registrar of the names of the persons
designated to be responsible for preparation and filing of records as required
by Act 1254 of 1995. Lists of births and deaths shall be kept by each hospital
or funeral home. Said list shall be made available to the State Registrar upon
request.
RULE 20.0 MATCHING
OF BIRTH AND DEATH CERTIFICATES
(Reference: Section 7 of Act 1254 of 1995)
When carrying out the birth and death matching program, the
State Registrar shall establish written guidelines which provide the standards
for determining a match does exist. These standards shall specify the
information about the decedent which should be available and which should be
compared to the information on the birth certificate before a match can be
made. These items include as a minimum; name of decedent; name of father and
maiden name of mother; date of birth or age of decedent; State of birth of
decedent; marital status of decedent. No match shall be made unless there is
documented proof of the fact of death.
The date of death, the State where death occurred, and the
death certificate number shall be posted to the birth certificate.
RULE 21.0 PENALTIES
(Reference: Section 4 of Act 1254 of 1995)
(a) The following persons shall be punished
by a fine of not more than ten thousand dollars ($10,000) or by imprisonment
for not more than five (5) years, or both:
(1) Any person who willfully and knowingly
makes any false statement in a certificate, record or report required to be
filed under these Rules, or in an application for an amendment thereof or in an
application for a certified copy of a vital record, or who willfully and
knowingly supplies false information intending that such information be used in
the preparation of any such report, record, or certificate, or amendment
thereof; or
(2) Any person who
without lawful authority and with the intent to deceive, makes, counterfeits,
alters, amends or mutilates any certificate, record or report required to be
filed under these Rules or a certified copy of such certificate, record or
report; or
(3) Any person who
willfully and knowingly obtains, possesses, uses, sells, furnishes, or attempts
to obtain, possess, use, sell or furnish to another, for any purpose of
deception, any certificate, record, report, or certified copy thereof so made,
counterfeited, altered, amended or mutilated; or
(4) Any person who, with the intent to
deceive, willfully and knowingly obtains, possesses, uses, sells, furnishes, or
attempts to obtain, possess, use, sell or furnish to another any certificate of
birth or certified copy of a certificate of birth knowing that such certificate
or certified copy was issued upon a certificate which is false in whole or in
part or which relates to the birth of another person, whether living or
deceased; or
(5) Any person who
willfully and knowingly furnishes or processes a certificate of birth or
certified copy of a certificate of birth with the knowledge or intention that
it be used for the purpose of deception by a person other than the person to
whom the certificate of birth relates; or
(6) Any person who without authority
possesses any certificate, record or report required by these Rules or a copy
or certified copy of such certificate, record or report knowing same to have
been stolen or otherwise unlawfully obtained.
(b) The following persons shall be punished
by a fine of not more than one thousand dollars ($1,000) or by imprisonment for
not more than one (1) year, or both:
(1) Any
person who willfully and knowingly refuses to provide information required by
these Rules adopted hereunder; or
(2) Any person who willfully and knowingly
transports or accepts for transportation, interment or other disposition, a
dead body without an accompanying permit as provided in these Rules;
or
(3) Any person who willfully and
knowingly neglects or violates any of the provisions of these Rules or refuses
to perform any of the duties imposed upon him by these Rules.
RULE 22.0 SEVERABILITY
(Reference: Section 31 of Act 1254 of 1995)
If any provision of these Rules or the application thereof to
any person or circumstances is held invalid, such invalidity shall not affect
other provisions or applications of these Rules which can be given effect
without the invalid provisions or applications, and to this end the provisions
of these Rules are declared to be severable.
REPEAL All Rules and parts of Rules in conflict herewith are
hereby repealed.
Appendix A
Click
here to view image
MAIL OR FAX TO ARKANSAS DEPARTMENT OF HEALTH
CENTER FOR HEALTH STATISTICS
4815, W MARKHAM ST SLOT # 19
LITTLE ROCK, AR 72205
FAX (501) 6661-2544
INSTRUCTIONS FOR COMPLETING
THE INDUCED TERMINATION OF PREGNANCY REPORT:
VR-29
|
ITEM
|
INSTRUCTION
|
|
1. Facility Name
|
Enter name of facility or give address if not a
clinical or hospital.
|
|
2. City, Town, or Location
|
Enter name of city, town, or location of pregnancy
termination.
|
|
3. County
|
Enter name of county where pregnancy termination
occurred.
|
|
4. Age
|
Enter age in years of patient at her last
birthday.
|
|
5. Married
|
Check "Yes" if the patient was legally married at any
time between conception and termination. Otherwise check "No."
|
|
6. Date
|
Enter Month-Day-Year of pregnancy termination (e.g.
10-23-2001).
|
|
7. Residence
|
|
|
a. State
|
Enter name of state in which patient lives.
|
|
b. County
|
Enter name of county in which patient lives.
|
|
c. City
|
Enter name of city in which patient lives.
|
|
d. Inside City
|
Enter Yes, No, or Unknown.
|
|
e. ZIP Code
|
Enter ZIP code of patient's residence.
|
|
8. Hispanic Origin
|
Check No or Yes; if Yes SPECIFY Mexican, Cuban, Puerto
Rican, etc.
|
|
9. Race
|
Check White, Black, American Indian, or Other. If
Other, specify.
|
|
10. Education
|
Fill in number for highest grade of school completed.
If more than 5 years of college, enter 5+.
|
|
11. Date of Last Menses
|
Enter date that last menses began (e.g. 5-14-2001
).
|
|
12. Previous Pregnancies
|
|
|
a. Now Living
|
Enter the number of live births that are still
living.
|
|
b. Now Dead
|
Enter the number of live births that have died.
|
|
c. Spontaneous
|
Enter the number of spontaneous abortions
(miscarriages) that have occurred.
|
|
d. Induced
|
Enter the number of PREVIOUS induced abortions that
have occurred.
|
|
No. 13 Reference(s): Act 934 of 2015
(§
20-16-1406)
|
|
13. Parental Consent
|
Check Yes or No on each item
|
|
a. Consent Required
|
|
|
b. Consent Obtained
|
|
|
c. Judicial Waiver Obtained
|
|
|
No. 14 Reference(s): Act 171 of 2013
(§
20-16-814)
|
|
14. Probable Post-Fertilization
|
(PPF)
|
|
a. PPF age
|
Enter estimate of probable post-fertilization age. DO
NOT USE RANGES.
|
|
b. Method
|
Check method for determining PPF age
|
|
c. PPF Age Undetermined
|
List the basis of the determination that a medical
emergency existed.
|
|
d. PPF 20 weeks or more
|
List the basis of the determination that the pregnant
woman had a condition which so complicated her medical condition as to
necessitate the immediate abortion of her pregnancy to avert her death or to
avert serious risk of substantial and irreversible physical impairment of major
bodily function of the pregnant women, not including psychological or emotional
condition.
|
|
15. Procedure
|
Check ONLY ONE type of procedure that terminated this
pregnancy.
|
|
16. Best Opportunity for Survival
|
Check Yes or No. If No, specify reason for choice of
method.
|
|
No. 17 References(s): Act 801 of 2019
(§
20-16-604)
|
|
17. Did Abortion Result in Live Birth
|
Check Yes or No
|
|
18. Name of Physician
|
Enter name of attending physician
|
|
19. Staff Person Name
|
Enter name and telephone number of staff person
completing this report.
|
Filing Instructions: The report must be filed monthly. Mail or
fax to:
Arkansas Department of Health
Health Statistics Branch
4815 West Markham Street, Slot #19
Little Rock, AR 72205
Fax: (501)661-2544
