Department of Health and Human Services 
OFFICE OF 
INSPECTOR GENERAL 
PATERNITY ESTABLISHMENT 
Use of Alternative Sites for 
Voluntary Paternity Acknowledgment 
JUNE GIBBS BROWN 
Inspector General 
JULY 1999 
06-98-00052  OFFICE OF INSPECTOR GENERAL 
The mission of the Office of Inspector General (OIG), as mandated by Public Law 95-452, is to 
protect the integrity of the Department of Health and Human Services programs as well as the 
health and welfare of beneficiaries served by them.  This statutory mission is carried out through a 
nationwide program of audits, investigations, inspections, sanctions, and fraud alerts.  The 
Inspector General informs the Secretary of program and management problems and recommends 
legislative, regulatory, and operational approaches to correct them. 
Office of Evaluation and Inspections 
The Office of Evaluation and Inspections (OEI) is one of several components of the Office of 
Inspector General.  It conducts short-term management and program evaluations (called 
inspections) that focus on issues of concern to the Department, the Congress, and the public.  The 
inspection reports provide findings and recommendations on the efficiency, vulnerability, and 
effectiveness of departmental programs. 
OEI's Dallas Regional Office  prepared this report under the direction of Chester B. Slaughter, 
Regional Inspector General, and Judith V. Tyler, Deputy Regional Inspector General. 
Principal OEI staff included: 
REGION  HEADQUARTERS 
Blaine Collins
 Alan Levine, Program Specialist 
Ruth Ann Dorrill
 Linda Hall 
Marnette Robertson

Clark Thomas, Ph.D.

Nancy Watts

Lisa White

FIELD 
Lucille Cop 
Vincent Greiber 
Ianna Kachoris 
Thomas Purvis 
Graham Rawsthorn 
To obtain copies of this report, please call the Dallas Regional Office at 214-767-3310. 
Reports are also available on the World Wide Web at our home page address: 
http://www.dhhs.gov/progorg/oei  Use of Alternative Sites for Voluntary 
Paternity Acknowledgment 
PURPOSE 
This report describes the early implementation efforts of State child support agencies to offer 
voluntary paternity acknowledgment services through alternative sites. 
RESULTS IN BRIEF 
We found about half of the States currently offer acknowledgment services through some of their 
public assistance offices.  Few States, however, have yet expanded services to other sites that 
child support agencies believe are potentially important to their paternity establishment efforts. 
State efforts to encourage participation have met reluctance by some entities due to time demands 
on limited staff and lack of financial incentives.  Typical services offered through alternative sites 
include distribution of public outreach materials explaining voluntary acknowledgment and, to a 
lesser degree, personal assistance to parents in completing paternity acknowledgments.  Many 
State child support agencies have yet to develop adequate methods of monitoring and evaluating 
alternative sites. We offer a number of suggestions to promote use of alternative sites by 
capitalizing on and refining effective practices now being used in some localities. 
BACKGROUND 
As part of the Personal Responsibility and Work Opportunity Reconciliation Act of 1996, 
Congress requires State child support agencies to provide voluntary paternity acknowledgment 
services through in-hospital acknowledgment programs and through the State agency responsible 
for maintaining birth records.1  To further expand services to unmarried parents, the Act allows, 
but does not require, States to offer acknowledgment services through other entities.2  If States 
use this added flexibility to expand acknowledgment services, the law requires State child support 
agencies to administer alternative sites in the same manner as in-hospital programs. 
The Office of Child Support Enforcement (OCSE) recently issued regulations on paternity 
establishment.3  These regulations specify that ... State procedures governing hospital-based 
programs and birth record agencies must also apply ... to alternative sites designated by the 
State.  The regulations also impose certain requirements on alternative sites involved in 
acknowledgment efforts, including ... undergoing training, being evaluated annually, providing 
oral and written information to mothers and putative fathers, and transmitting the 
acknowledgments to the State registry of birth records.  States may decide which entities to use, 
but OCSE regulations provide a list of possible alternative sites including child support, public 
assistance, and food stamp offices, public health clinics (including WIC centers), private health 
care providers, Head Start and child care facilities, child care providers, Community Action 
1
 Agencies and Community Action Programs, secondary schools, Legal Aid agencies, private 
attorneys, and similar entities that provide health, welfare and/or social services. 
This report focuses on expansion of acknowledgment services through these discretionary 
alternative sites.  Excluded from this discussion are the voluntary paternity acknowledgment 
services provided through hospitals, other birthing centers, vital records offices and local child 
support offices.4  We received survey responses on alternative site activity from all States and the 
District of Columbia.5  The following preliminary findings are provided to assist OCSE in its 
efforts to monitor State progress and provide technical assistance to promote early 
implementation efforts. 
This study was conducted in accordance with the Quality Standards for Inspections issued by the 
Presidents Council on Integrity and Efficiency. 
FINDINGS 
Public Assistance Agencies Participate in Voluntary Paternity Acknowledgment Efforts in 
Twenty-six States. 
State child support agencies have involved public assistance offices in acknowledgment efforts 
more frequently than other alternative sites.  Sixteen States report offering acknowledgment 
services through one hundred percent of local public assistance offices, while ten other States 
report partial implementation.  Providing voluntary acknowledgment services through public 
assistance offices seems a natural fit in many States for several reasons.  These agencies 
administer Temporary Assistance to Needy Families programs and often handle eligibility for 
Medicaid, food stamps and other human service programs.  Caseworkers at public assistance 
offices often see clients with children who do not have paternity established.  Clients may feel 
more comfortable dealing with their public assistance caseworker who assists them with child 
care, transportation and work-related matters.  Application and re-determination interviews 
provide opportunities for clients to receive information and sign voluntary paternity 
acknowledgment forms.  Additionally, in many States, child support and public assistance 
agencies have very strong inter-agency relationships, making training and coordination efforts less 
challenging than with other alternative sites. 
Participation by Entities Other Than Public Assistance Offices is Still Very Limited. 
State child support agencies have begun to offer voluntary acknowledgment services through a 
variety of other alternative sites.  Table 1 lists the number of States that report using alternative 
sites in their acknowledgment programs.6  Two sites on the list, public health clinics and food 
stamp offices, may be viewed as expansions of service within agencies that already offer 
acknowledgment services.  In many States, public health clinics, the second most frequently used 
alternative site, are administered through the vital records agency.  Therefore, many of these 
States have simply expanded voluntary acknowledgment services beyond their vital records 
offices to public health clinics.  Similarly, food stamp programs are often administered through 
2
 public assistance offices.  Other activities, however, clearly represent expansions of service to new 
locations.  Several States now use Women, Infant and Children (WIC) centers, high schools and 
Head Start agencies in their acknowledgment programs.  Some additional entities, such as 
fatherhood organizations, appear to offer voluntary acknowledgment services, yet may not be 
counted as alternative sites by State child support agencies.7 
TABLE 1: Participation and Importance of Alternative Sites in State 
Voluntary Paternity Acknowledgment Programs 
Alternative Site  States Currently  States Considering 
Using Site  Site Important 
Public Assistance Offices  26  36 
Public Health Clinics  15  26 
High Schools  11  18 
Food Stamp Offices  10  21 
Head Start Agencies  9  21 
Private Doctors Offices  9  19 
WIC Centers  8  22 
Middle Schools  5  12 
Medicaid HMO Facilities  2  16 
Pre-natal Clinics  N/A  26 
It is important to note that the responses summarized in Table 1 do not reflect the extent to which 
a particular site participates Statewide.  That is, use of an alternative site may occur in only one or 
a few locations within a State.  Some State child support agencies are testing alternative sites 
through pilot programs or have initiated participation only in selected geographic areas which 
may be expanded in the future. 
Participation by Certain Alternative Sites is Seen as Important by Child Support Agencies. 
As listed in Table 1, State child support agencies believe participation by several alternative sites 
is important to their voluntary paternity establishment programs.  More than half of States view 
public assistance offices, public health clinics and pre-natal clinics as important sites for 
acknowledgment services.  More than a third of States consider WIC centers, Head Start offices, 
food stamp offices, doctors offices and high schools as potentially important to their 
acknowledgment programs.  However, many of the possible alternative sites listed in 
OCSE regulations are not viewed as important by most respondents.  For example, only nine 
respondents indicated that providing voluntary acknowledgment services through child care 
3
 providers would be important to their program.  As expected in early implementation, more States 
view alternative sites as important than currently use those sites in their acknowledgment efforts. 
Most State Child Support Agencies Have Made at Least Some Outreach Efforts to Alternative 
Sites, But Some Entities are Reluctant to Participate. 
To expand acknowledgment services, most States have made contact with other entities.  Fifteen 
State child support agencies, however, report making no efforts to expand acknowledgment 
services to alternative sites.8  Most agencies indicate they use one of the following methods to 
attract new participants: presentations at meetings and/or conferences (33 States), conversations 
between key personnel (28), memos/letters sent to alternative site local offices (21), or phone 
calls to alternative site local offices (16).  According to one child support administrator 
responsible for outreach to other entities, personal contact is critical because key people at the 
alternative sites must be committed to the program.  This official offered several examples of sites 
that participated in paternity establishment efforts, but failed to generate many acknowledgments. 
He suggested that other sites were more successful because their leaders were committed to the 
project and encouraged staff to discuss voluntary paternity acknowledgment with clients. 
Most State child support agencies who have conducted outreach report that some entities are 
reluctant to provide voluntary acknowledgment services.  Although only three States report 
reluctance by most or all alternative sites contacted, another twenty States report reluctance 
by half or fewer contacted sites.9 
Lack of Resources is Cited as the Most Significant Barrier to Participation of Alternative 
Sites. 
State child support agencies identified barriers that hamper participation by alternative sites. In 
general, other entities often see the voluntary paternity acknowledgment program as a potential 
drain on limited staff time.  Twenty-eight States report sites they approached were too busy with 
their primary function and 25 States responded that entities lacked the manpower to offer such 
services.  Fourteen States report the absence of any financial incentive is a barrier to 
participation.  Despite having the authority to use Federal matching funds to pay other entities for 
completed paternity acknowledgments, only four State child support agencies report paying 
alternative sites for any services.  By comparison, 20 State child support agencies paid hospitals 
for completed voluntary acknowledgments in 1996.10 
Most Participating Alternative Sites Provide Forms and Written Materials, But May Not 
Actually Assist Parents in Completing Paternity Acknowledgments. 
Table 2 shows the number of States in which alternative sites are providing different types of 
acknowledgment services.  The most common service is provision of outreach materials to the 
general public.  Typical outreach materials are wall posters, brochures or pamphlets that explain 
the mechanics and benefits of voluntary paternity acknowledgment.  In several States, alternative 
sites currently participate in outreach, but offer no further services such as making 
4
 acknowledgment forms available to the public.  While 21 States report that their public assistance 
agencies distribute acknowledgment forms, only a handful of States currently make 
acknowledgment forms available through high schools, WIC Centers, or Head Start facilities. 
Some alternative sites also provide personal assistance to individuals and accept completed 
acknowledgment forms.  Personal assistance may include notification of rights and 
responsibilities,11 or guidance on how to present the idea of acknowledging to the other parent. 
Fewer alternative sites accept acknowledgment forms from the public and forward them to the 
appropriate agency (typically the child support agency or the vital records agency.)  As shown in 
the last column of Table 2, only 15 States report that even their public assistance agencies 
currently provide this higher level service. 
TABLE 2: Number of States in Which Alternative Sites Provide Services 
Alternative Site  Outreach  Acknowledgment  Personal  Accept & 
Materials  Forms  Assistance  Forward Forms 
Public Assistance Offices  26  21  17  15 
Public Health Clinics  15  13  8  4 
High Schools  11  4  3  3 
Food Stamp Offices  10  7  6  4 
Private Doctors Offices  9  5  1  1 
Head Start Facilities  9  5  5  4 
WIC Centers  8  5  4  2 
Most State Child Support Agencies Provide Training or Materials to Alternative Sites, and 
Some Have Begun to Monitor Their Performance. 
Thirty-five State child support agencies report providing materials or training to other entities. 
Additionally, vital records agencies perform some of these tasks in 15 States.12  In nine States, 
however, neither the child support agency nor the vital records agency report providing any 
training or materials to other entities.  Eighteen State child support agencies report monitoring the 
performance of most or all alternative sites, and an additional three States said their vital records 
agency performs this monitoring function.  The most common form of monitoring involves 
tracking the number of acknowledgments generated through individual sites. Fourteen State child 
support agencies and three vital records agencies monitor alternative sites by this method. 
However, fewer than ten States report tracking alternative sites through more in-depth methods 
such as personal conversations, telephone calls or on-site visits.  Even less monitoring of 
acknowledgment services may occur with entities that are not officially considered alternative 
sites, such as fatherhood organizations.  One approach to monitoring alternative sites was 
developed for Cook County, Illinois where a single unit (3-4 staff members) acts as a liaison with 
5
 all alternative sites.  This unit maintains contact with participating entity staff and insures periodic 
training. 
RECOMMENDATIONS 
While State programs to offer voluntary paternity acknowledgment services through alternative 
sites are still in early stages of development, many preliminary efforts appear promising. 
Therefore, we recommend that the Office of Child Support Enforcement (OCSE) capitalize on 
these early efforts by promoting refinement of potentially effective approaches.  As we offer these 
suggestions, we recognize that OCSE has already taken action to promote innovation in 
acknowledgment services.  For example, OCSEs 8th National Training Conference highlighted 
effective practices in a session on expanding voluntary acknowledgment services through 
alternatives sites. 
Focus technical assistance on the most promising sites. 
States are using the flexibility afforded by welfare reform legislation and OCSE regulations to 
expand voluntary paternity acknowledgment services offered through alternative sites, especially 
public assistance agency offices.  Although OCSE regulations list a large number of potential 
sites, our research suggests that a few (public health and pre-natal clinics, WIC centers, food 
stamp offices, Head Start agencies, doctors offices and high schools) clearly have the greatest 
potential.  To maximize the impact of technical assistance, OCSE should primarily focus on 
helping States expand services through these sites. 
Minimize complexity for participating entities. 
Lack of staff is viewed as a significant barrier to participation by alternative sites.  To address this 
barrier, OCSE should assist States in simplifying the role of alternative site staff in the voluntary 
paternity acknowledgment process.  For instance, several states have established toll-free phone 
lines through which parents may hear a recorded explanation of the rights and responsibilities of 
acknowledging paternity or talk directly with a child support specialist.  Many States have also 
simplified processes through which sites may order needed materials or arrange for training of 
new staff.  These efforts reduce the burden on alternative site staff, while insuring that parents 
may obtain accurate, consistent information. 
Encourage full-service participation. 
While most participating alternative sites provide public outreach materials about voluntary 
acknowledgment of paternity, many do not offer full services that would enable parents to 
complete and submit acknowledgments through the site.  By encouraging alternative sites to assist 
parents in completing voluntary acknowledgments, State child support agencies could increase the 
use of acknowledgments and better utilize resources devoted to alternative sites.  To accomplish 
this goal, at least one State makes the percentage of cases with paternity established a 
performance measure for its local public assistance office managers.  Thus, these managers have a 
6
 direct incentive to give their staff the training and resources to assist parents in completing 
voluntary paternity acknowledgments. 
Consider developing incentives for alternative site participation. 
Lack of financial incentives is seen as a significant barrier to participation by other entities. 
Payment for completed voluntary acknowledgments, which currently occurs in only a few States, 
may be one way to encourage alternative site participation.  States might focus financial incentives 
on sites - such as public assistance offices and public health clinics - which are full service sites, 
appear to be promising, and are regarded as important by State child support officials.  However, 
some State child support administrators surveyed considered payment for acknowledgments akin 
to offering a bounty for completed acknowledgments.  On the other hand, others view a small 
($10 - $20) payment as minimal compensation for assisting the State in the important task of 
paternity establishment. 
Encourage State agencies to more closely monitor sites. 
While virtually all States provide training or materials to participating alternative sites, relatively 
few appear to monitor the performance of these sites.  Monitoring not only allows State child 
support agencies to review the performance of sites, it also helps insure consistent service to 
parents.  To encourage monitoring, OCSE may wish to highlight the activities of States that do 
actively monitor alternative sites.  At a minimum, effective monitoring involves tracking the 
amount of outreach materials distributed through other entities and the number of 
acknowledgments completed at sites.  More extensive methods may include periodic visits to sites 
to conduct training and assess progress. 
AGENCY COMMENTS 
The Administration for Children and Families (ACF) notes that OCSE has made a commitment to 
State development of alternative sites by allowing States to provide up to $20 to hospitals, State 
birth record agencies, and other entities designated by the State and participating in the States 
voluntary paternity establishment program for each voluntary acknowledgment obtained pursuant 
to an agreement with the child support agency.13  ACF also anticipates that, in an effort to 
increase paternity establishment ratios to the levels PRWORA requires, States will work closely 
with, and monitor, the progress of paternity acknowledgment in alternative sites. 
While ACFs comments reaffirm that financial incentives are available for alternative sites, our 
study shows that few States as yet pay alternative sites.  On this issue and others addressed in our 
recommendations, we continue to believe that States could benefit from further Federal leadership 
and focused technical assistance as they seek to expand voluntary paternity acknowledgment 
services through alternative sites. 
ACFs comments are provided in their entirety in Appendix A. 
7
 ENDNOTES

1. The State agency responsible for maintaining birth records is also known as the vital records 
agency or the public health statistics agency.  We use the term vital records agency in this 
report. 
2. The terms alternative sites and other entities are used interchangeably here. 
3. OCSE Action Transmittal 99-02 (March 10, 1999). 
4. Our office previously evaluated in-hospital voluntary paternity acknowledgment programs 
and presented the results in August of 1997 in a series of four reports entitled In-Hospital 
Voluntary Paternity Acknowledgment Program: State Agency and Birthing Hospital 
Implementation (OEI-06-95-00160); Hospital Experiences in Sample States (OEI-06-95-
001610; Effective Practices in Hospital Staff Training (OEI-06-95-00162); and Effective 
Practices in Parent Outreach (OEI-06-95-00163).  Also, see our companion reports Paternity 
Establishment: Use of Voluntary Paternity Acknowledgments (OEI 06-98-00053) and Paternity 
Establishment: States Use of Genetic Testing (OEI 06-98-00054). 
5. While every State returned the survey, three States did not fill out a series of questions on 
other entities.  Other questions on alternative sites were answered by varying numbers of 
respondents. The effect, if any, of non-response to individual questions is that our findings 
may understate actual alternative site activity. 
6. This table does not include sites that fewer than twelve State child support agencies believed 
would be important to their voluntary paternity program. 
7. Our data collection concentrated on the other entities suggested in OCSE Action Transmittal 
98-01 (January 8, 1998) and, therefore, did not ask about fatherhood organizations or other 
community based organizations (CBOs).  One State did report contacting CBOs to offer 
acknowledgment services and fatherhood organizations have publicized offering services to 
assist fathers in acknowledging paternity.  Any unofficial involvement of CBOs may create 
problems for State child support agencies, however, because they may lack mechanisms 
through which to monitor or evaluate the efforts of these organizations. 
8. Some of these fifteen States may not yet use voluntary paternity acknowledgments outside 
hospitals and birthing centers.  For more details, see our companion report, Paternity 
Establishment: Use of Voluntary Paternity Acknowledgments (OEI 06-98-00053). 
9. By contrast, 14 States report no reluctance at all by the alternative sites approached to 
provide acknowledgment services. 
10. As indicated in our report, In-hospital Voluntary Paternity Acknowledgment Program: 
State Agency and Birthing Hospital Implementation (OEI-06-95-00160), August, 1997. 
8
 11. If an alternative site distributes acknowledgment forms, it is required to provide parents 
with written and oral notification of their rights and responsibilities regarding voluntary 
paternity acknowledgment.  For more details, see our companion report, Paternity 
Establishment: Notification of Rights and Responsibilities for Voluntary Paternity 
Acknowledgment(OEI 06-98-00051). 
12. Nine State vital records offices conduct on-site training of alternative site staff.  For more 
details see our companion report, Paternity Establishment: The Role of Vital Records Agencies 
(OEI 06-98-00055). 
13. While the original ACF Response in Appendix A suggests that other entities must provide 
prenatal or birthing services to be eligible for the $20 payment, OCSE clarified that States 
could provide payment to any alternative site participating in the States voluntary paternity 
establishment program pursuant to an agreement with the child support agency, as indicated in 
OCSE Action Transmittal 99-02. 
9