Department  of Health  and  Human  Services 
OFFICE  OF 

INSPECTOR  GENERAL 

IN-HOSPITAL  VOLUNTARY  PATERNITY 

ACKNOWLEDGMENT  PROGRAM 

Effective  Practices  in  Hospital  Staff  Training 
JUNE  GIBBS  BROWN 
Inspector  General 
AUGUST  1997 
OEI-06-95-00162  OFFICE  OF INSPECTOR  GENERAL 
The mission  of the Office of Inspector  General  (OIG), as mandated  by Public Law 954.52,  as 
amended,  is to protect  the integrity  of the Department  of Health and Human  Services  (HHS) 
programs  as well as the health and welfare  of beneficiaries  served by those programs.  This statutory 
mission  is carried  out through  a nationwide  network  of audits,  investigations,  and inspections 
conducted  by three OIG operating  components:  the Office of Audit Services,  the Office of 
Investigations,  and the Office of Evaluation  and Inspections.  The OIG also informs  the Secretary  of 
HHS of program  and management  problems  and recommends  courses  to correct  them. 
OFFICE  OF EVALUATION  AND INSPECTIONS 
The OIGs Office of Evaluation  and Inspections  (OEI) conducts  short-term  management  and program 
evaluations  (called inspections)  that focus on issues of concern  to the Department,  the Congress,  and 
the public.  The findings  and recommendations  contained  in these inspection  reports  generate  rapid, 
accurate,  and up-to-date  information  on the efficiency,  vulnerability,  and effectiveness  of departmental 
programs. 
OEIs Dallas Regional  Office prepared  this report under  the direction  of Chester  B. Slaughter, 
Regional  Inspector  General. 
Project  Staff included: 
DALLAS REGION  HEADQUARTERS 
Ruth Ann Dorrill,  Project  Leader 
 Ann OConnor,  Program  Specialist 
Lisa Lesh,  Intern 

Marnette  Robertson 

For additional  copies of this report,  please contact the Dallas Regional  Office at (800) 8488960.  Department  of Health  and  Human  Services 
OFFICE  OF 

INSPECTOR  GENERAL 

IN-HOSPITAL  VOLUNTARY  PATERNITY 

ACKNOWLEDGMENT  PROGRAM 

Effective  Practices  in  Hospital  Staff  Training 
JUNE  GIBBS  BROWN 
Inspector  General 
AUGUST  1997 
OEI-06-95-00162  EXECUTIVE  SUMMARY 
PURPOSE 
This report  describes  State best practices  in training  birthing  hospital  staff on voluntary 
paternity  acknowledgment  procedures. 
BACKGROUND 
Federal  law requires  that States implement  hospital-based  programs  for the voluntary 
acknowledgment  of paternity,  seeking  to facilitate  at-birth  paternity  establishment  for children 
born to unmarried  parents.  Paternity  researchers  agree that the most opportune  time for 
paternity  establishment  is the happy  hour  in the hospital  immediately  following  birth. 
Within  this narrow  window  of exposure  to unmarried  parents,  birthing  hospital  staff must be 
prepared  to inform  parents  about voluntary  acknowledgment.  State child  support  agencies 
are required  to make available  voluntary  acknowledgment  materials  for training  hospital  staff 
and must monitor  birthing  hospital  compliance  on at least an annual  basis.  Hospital  staff are 
required  to provide  mothers  and fathers  with both written  materials  and oral explanations 
regarding  their  rights  and responsibilities.  They  must therefore  be educated  on the 
mechanics  of incorporating  paternity  acknowledgment  into pre-existing  birth  registration 
methods,  and on the procedures  and effects  of acknowledging. 
FINDINGS 
In collecting  information  nationwide  for our companion  report  on state agency  and birthing 
hospital  implementation  of voluntary  paternity  acknowledgment  programs,  we found most 
State child  support agencies  (IV-D) had launched  efforts  to inform  birthing  hospital  staff of 
the paternity  effort  and to provide  support to such staff in communicating  with unmarried 
parents.  However,  after surveying  a sample of hospitals  on their  contact  with IV-D and their 
comfort  level  in administering  paternity  acknowledgment  procedures,  we found that materials 
often did not appear  to meet the needs of birthing  hospital  staff.  This  report  describes 
effective  State practices  for training  hospital  birthing  staff in understanding  paternity 
acknowledgment  and their  responsibility  for talking  with unmarried  parents  about this 
important  issue.  These highlighted  practices  in no way represent  all efforts  nationwide,  but 
give a snapshot  of procedures  that have been reported  to us by agencies  and hospitals  in the 
course  of our study. 
Guidelinesfor  Creating HospitalStaff Training Materials 
Training  materials  should clearly  communicate  both the mechanics  of acknowledging  and the 
purpose  and  benefits  of paternity  acknowledgment. 
Training  materials  should contain  simple,  clear  instructions  and clearly  delineate  the roles 
and responsibilities  of both  State agencies  and hospital  staff. 
i  The usefulness  and clarity  of training  materials  are improved  by dividing  them  into separate 
sections  on administrative  procedure  and parental  contact. 
Training  materials  should always  include contact  information  on current  child  support  staff to 
whom paternity  questions  may be directed  or new training  needs articulated. 
HospitalStaff Training Methods 
Training  materials  may be more effective  when geared  toward  informal  use,  in recognition 
that much of staff training  is ad hoc and takes place within  the varied  schedules  of hospital 
staff. 
Increased  recognition  and attention  to training  materials  can be achieved  through  repetitive 
use of familiar  logos,  graphics,  slogans and acronyms. 
On-site  visits,  workshops  and seminars,  which  allow more personalized  training  and  greater 
interaction  between  agency  personnel  and birthing  hospital  staff,  appear to be more  effective. 
Using multiple  training  methods  helps to ensure  a clear  and repetitive  message reaches  all 
varieties  of hospital  environments. 
Training  materials  are less likely  to be effective  without  direct  contact  between  child  support 
offices  and hospital  staff. 
Connecting HospitalAssessments to Staff Training 
Keying  staff training  materials  to hospital  assessment  outcomes  may allow  State child  support 
agencies  to more fairly  and accurately  evaluate  hospital  program  participation. 
Linking  staff training  and hospital  assessment provides  a framework  within  which  the child 
support agency  may address any problems  of hospital  noncompliance. 
AGENCY  COMMENTS 
We have worked  in close partnership  with the Office  of Child  Support Enforcement  (OCSE) 
throughout  the conduct  of this inspection.  Although  we did not receive  formal  comments 
from  ACF on our draft reports,  they demonstrated  through  their collaboration  a general 
agreement  with this report  and the companion  reports.  We worked  with OCSE in developing 
a research  methodology,  provided  extensive  briefings  on study findings  and created  additional 
documents  to meet agency  needs.  We appreciate  their  cooperation  and guidance,  and will 
continue  to work with them on the issues raised  in these reports. 
ii  TABLE  OF  CONTENTS 
PAGE 
EXECUTIVESUMMARY  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  i 
INTRODUCTION  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 
FINDINGS 
Guidelines  for Hospital  Staff Training  . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 
Hospital  Staff Training  Methods  . . . . . . . . . . . . , . . . . . . . . . . . . . . . . . . 6 
Connecting  Hospital  Assessments  to Staff Training  . . . . . . . . . . . . . . . . . . . .  8 
CONCLUSIONS  . . . . . . . . . . . . . . . . . . . ..I....................  10 
APPENDICES 
A.  Staff Fact Sheets  ...................................  A-l 
B.  Consequences  Flow Chart  ..............................  B-l 
C.  Instruction  Sheets  ...................................  .C-1 
D.  Reminder  Checklist  ..................................  D-l 
E.  Roles of Key Players  ..................................  E-l 
F.  Affidavit  Instructions  ..................................  F-l 
G.  ParentQ&A  .....................................  G-l 
H.  Legal Advice  ......................................  H-l 
I.  Hospital  Needs Surveys  ................................  I-l 
J.  Program  Objectives  ...................................  J-1 
. . . 
111  INTRODUCTION 
PURPOSE 
This report  describes  State best practices  in training  birthing  hospital  staff on voluntary 
paternity  acknowledgment  procedures. 
BACKGROUND 
The Omnibus Budget Reconciliation  Act of  1993 (OBRA) amends the Child  Support Title 

IV-D of the Social  Security  Act,  requiring  States to implement  hospital-based  programs 

for the voluntary  acknowledgment  of paternity.  The objective  of these programs  is to 

facilitate  at-birth  paternity  establishment  for children  born  to unmarried  parents. 

Establishment  of paternity  at birth  has many  administrative,  financial  and emotional 

benefits.  Mothers  often lack information  about the importance  of and methods  for 

establishing  paternity.  Consequently,  they may not seek to establish  paternity  until  a point 

at which the process  becomes  more difficult. 

Paternity  researchers  agree that the most opportune  time for paternity  establishment  is the 

happy  hour  in the hospital  immediately  following  birth  and before  the release  of the 

mother  and child.  Within  this narrow  window  of exposure  to unmarried  parents,  birthing 

hospital  staff must be prepared  to inform  parents  about the option  of voluntary 

acknowledgment.  Without  an establishment  of paternity,  unmarried  mothers  may never 

obtain  a child  support order  and gain access to the enforcement  services  of their  child 

support office.  Under  OBRA, State child  support agencies  must,  among  other 

requirements,  make available  voluntary  acknowledgment  outreach  materials,  including 

information  on parental  rights  and responsibilities,  and materials  for training  hospital  staff. 

Also relative  to hospital  staff training,  State child  support  agencies  must monitor  birthing 

hospital  compliance  on at least an annual  basis. 

The Personal  Responsibility  and Work  Opportunity  Reconciliation  Act of  1996 

(PRWORA) expands the role of hospital  staff by requiring  them to provide  mothers  and 

fathers  with both written  materials  and oral explanations  regarding  the rights and 

responsibilities  of paternity  establishment.  As interpreted  by the Office of Child  Support 

Enforcement  (OCSE),  the intent  of both OBRA and PRWORA  is to make voluntary 

paternity  acknowledgment  part of the birth  registration  process.  Therefore,  birthing 

hospital  staff must not only  be able to inform  parents  of the consequences  of 

acknowledging  paternity,  but also be educated  on the mechanics  of incorporating  paternity 

acknowledgment  into pre-existing  birth  registration  and documentation  procedures. 

This report,  which  describes  effective  State efforts  to educate hospital  birthing  staff is one 

of four reports  in a series on hospital-based  voluntary  paternity  acknowledgment 

programs.  Others  include  In-Hospital  Voluntary  Paternity  Acknowledgment  Programs: 

State Agency  and Birthing  Hospital  Implementation  (OEI-06-95-00160)  details  nationwide 

program  participation,  In-Hospital  Voluntary  Paternity  Acknowledgment  Programs: 
 Hospital  Experiences  in Sample States  (OEI-06-95-00161)  describes  program  usage based 
on survey  responses  from birthing  hospitals  and State agencies  in 15 sample States,  and 
In-Hospital  Voluntary  Paternity  Acknowledgment  Programs:  Effective  Practices  In Parent 
Outreach  (OEI-06-95-00163)  highlights  State efforts  to educate unmarried  parents. 
METHODOLOGY 
After preinspection  research,  we administered  comprehensive  mail  surveys  on the 
voluntary  paternity  acknowledgment  process  to State child  support and vital  records 
agencies  in every  State and the District  of Columbia  and to 566 birthing  hospitals  in a 
sample of  15 States.  In addition  to completing  the surveys  which provided  data for our 
primary  reports  on implementation  and hospital  experiences,  agencies  sent examples  of 
paternity  acknowledgment  training  and outreach  materials  and photocopies  of their birth 
certificates  and voluntary  paternity  acknowledgment  forms.  We received  completed 
surveys  and supplemental  materials  from both agencies  in every  State and from 429 (78 
percent)  of birthing  hospitals  sampled. 
The supplemental  materials  on hospital  staff training  included  manuals,  instruction  sheets, 
videos,  advertisements,  brochures  and workshop  curriculum  guides.  We conducted 
telephone  follow-up  approximately  six months  after receiving  these materials  to request 
any supplemental  training  documents  and received  a number  of new or updated  materials. 
Content  analysis  was conducted  and a smaller  number  of materials  and innovative  ideas 
were subjectively  selected  for inclusion  in this report. 
This study was conducted  in accordance  with the Quality  Standards  for Inspections  issued 
by the Presidents  Council  on Integrity  and Efficiency. 
2 
 FINDINGS 

In collecting  information  nationwide  for our primary  reports  on State agency  and birthing 
hospital  implementation  of voluntary  paternity  acknowledgment  programs  and hospital 
experiences  in a sample of States,  we found that most State child  support  agencies  (IV-D) 
had launched  efforts  to inform  birthing  hospital  staff of the paternity  effort  and to provide 
support to such staff in communicating  with unmarried  parents.  However,  after surveying 
a sample of hospitals  on their  contact  with IV-D and their  comfort  level  in administering 
paternity  acknowledgment  procedures,  we found suggested  training  materials  often did not 
meet the needs of birthing  hospital  staff.  Sometimes  this problem  was a matter  of poor 
distribution  and lack of follow-up  contact,  and sometimes  it was the fault of the materials 
themselves.  Regardless,  birthing  hospital  staff reported  confusion  over their  roles  in the 
paternity  programs  even though  they  showed a strong  willingness  to take responsibility  for 
such a role. 
This report  describes  effective  or innovative  training  practices  within  States which  are 
seeking to help birthing  hospital  staff understand  the acknowledgment  process  and to 
facilitate  their  responsibility  for talking  with unmarried  parents  about this important  issue. 
The first section below  details  guidelines  child  support agencies  should consider  when 
creating  hospital  staff training  materials.  The next section provides  examples  of effective 
practices  in which  a variety  of training  mediums  and methods  are employed.  The report 
ends with our conclusions  based on analysis  of the materials  and practices  made available 
to us.  These highlighted  practices  in no way represent  all efforts  nationwide,  but give a 
snapshot  of what has been reported  to us by State IV-D and vital records  agencies  and 
birthing  hospitals  in the course  of our data collection. 
GUIDELINES  FOR  HOSPITAL  STAFF  TRAINING 
Training MaterialsShould Clearly Communicate the Purpose of Paternity 
Acknowledgmentand its Benefits to Children, Unmarried Parents and Public Health. 
A number  of staff training  materials  we received  did a thorough  and admirable  job  of 
explaining  the administrative  details  of paternity  acknowledgment  but neglected  to briefly 
and clearly  describe  the overriding  purpose  of the paternity  effort.  They might  only 
mention  that paternity  programs  must by Federal  mandate  be implemented  in all birthing 
hospitals  but miss the opportunity  to explain  the public  health  and social  service  policy 
behind  the mandate.  This may lead hospital  staff to minimize  the importance  of the 
paternity  effort  and, even worse,  convey  a limited  and possibly  inaccurate  message to 
unmarried  parents.  If staff understand  the core  of the paternity  issue,  they  will not only 
be more motivated  to fulfill  their  role but will  also be more  competent  in explaining  the 
importance  of paternity  acknowledgment  to parents.  The child  support agency  in 
Connecticut  includes  copies  of relevant  State statutes with their hospital  information 
packets,  explaining  both the law and its public  policy.  Simple statements  describing  the programs  objectives  may go a long way toward 
highlighting  the significance  of the program  in the minds of staff.  Appendix  A includes 
simple fact sheets for hospital  staff which explain  the purpose  of paternity 
acknowledgment  and the importance  of the in-hospital  effort  in clear  and direct  language. 
Missouri  and New Jersey,  among  other  States, use nonmarital  birth  and poverty  statistics 
to convey  a sense of urgency  and importance,  and New Jersey  subtitles  all written 
materials  with the phrase  Preventing  Childhood  Poverty.  In Texas,  hospital  staff are 
given  a flow chart which  outlines  the process  of applying  for public  assistance  if the 
mother  has not acknowledged  (Appendix  B). 
Training Materials Should Contain Simple Instructionsand Clearly Delineate Roles and 
Responsibilitiesof Both StateAgencies and HospitalStaff. 
Birthing  hospital  staff are obligated  to provide  new parents  with information  on a wide 
variety  of important  topics  within  a very brief  time period.  Areas of concern  that must be 
addressed  during  the mothers  hospital  stay include  infant care,  home  safety,  breast 
feeding  and post-par-turn nutrition.  Unmarried  mothers,  often  due to youth  and lack of 
experience,  may be particularly  unprepared  for the responsibilities  of parenthood  and be 
even more likely  than married  mothers  to need greater  assistance  from hospital  staff in 
understanding  these health-related  issues. 
Child  support agencies  should be respectful  of the responsibility  of hospital  staff to convey 
a deluge of information  to parents  and should keep paternity  instructions  as simple as 
possible.  A number  of States including  Arkansas,  Arizona  and New Hampshire,  while 
still providing  more  in-depth  training  materials,  have condensed  the most important 
information  into a single  one or two-sided  sheet of paper  that describes  staff 
responsibilities  step-by-step  (see Appendix  C).  These single  sheets are often laminated  for 
easier use and distribution.  Staff may refer  to the supplementary  materials  should they 
desire more  information  but can easily  carry  around  or memorize  the single  sheet.  It also 
may be useful to provide  hospitals  with a checklist  of reminders  which would ensure  all 
appropriate  steps were taken  in the acknowledgment  process  (see Appendix  D). 
We found in our survey  of birthing  hospitals  that staff are often confused  about their  role 
in the process,  even when they understand  the paternity  effort  and its importance.  They 
may believe,  for example,  that only  child  support staff may explain  issues related  to the 
rights and responsibilities  of acknowledgment  or may overestimate  the parents  prenatal 
exposure  to paternity  information  and minimize  the importance  of their  own contact  with 
parents.  In response  to this confusion,  some States outline  not only  the responsibility  of 
hospital  staff in their  training  manuals,  but also the specific  roles  of the child  support 
agency  and the public  health  department  as they relate  to paternity  acknowledgment 
(Appendix  E).  This allows hospital  staff to understand  their  responsibilities  relative  to the 
other key players  and to better  see how they fit into the process.  The Usefulness and Clarityof Training Materialsare Improved by Dividing them into 
Separate Sections on Administrave Procedure and Parental Contact. 
There  are two aspects to fully  understanding  and facilitating  the paternity  effort:  the  nuts 
and bolts  of documenting  paternity  and the personal  and social  issues which  surround  the 
act of acknowledgment.  The most clear  and easily-readable  hospital  staff training 
documents  separate the  nuts and bolts  from the more  subjective  issues.  For example, 
the first section  of one staff training  manual  from California  explains  the importance  of 
paternity,  provides  a brief  history  of the program,  and discusses  related  issues such as the 
marital  status of the mother  and genetic  testing.  The second  section  outlines  exactly  what 
staff must do to complete  and document  acknowledgments. 
Because hospital  staff are accustomed  to dealing  with the birth  registration  process  and 
because the intent  of the Federal  requirements  is to make paternity  acknowledgment  a part 
of birth  registration,  child  support  agencies  may be well-advised  to include  administrative 
instructions  on paternity  acknowledgment  within this pre-existing  structure.  The child 
support agency  in Delaware  coordinated  with  its State vital  records  office to create  a 
document  which provides  instructions  for completing  each data element  on the paternity 
affidavit  using the same method  birth  registrars  are familiar  with from completing  birth 
certificates  (see Appendix  F). 
Although  it is crucial  for hospital  staff to be clear  on the administrative  details  involved  in 
completing  and filing  paternity  documentation,  staff are very  often placed  in the position 
of having  to answer  detailed  questions  and to explain  related  child  support and legal  issues 
to parents.  In addition,  PRWORA  requires  that hospital  staff provide  an oral description 
of the rights  and responsibilities  that accompany  acknowledgment.  A number  of States 
have created  staff training  materials  in a Question  and Answer  format  that outline 
typical  topics parents  may need to understand  (see Appendix  G).  These topics  include 
paternity  establishment  of siblings,  custody  and visitation,  public  assistance,  and 
procedures  for acknowledging  outside  the hospital.  Virginia  and other  States even include 
copies of child  support enforcement  applications  in materials  given to hospitals. 
Hospital  staff cannot  possibly  be expected  to answer  complex  legal questions  and give 
substantive  advice to new mothers,  but unmarried  parents  appear  to often have the same 
questions  which may at least be superficially  addressed  if hospital  staff are themselves 
given  such information.  To help hospital  staff resist the temptation  to go outside 
appropriate  boundaries  when providing  information,  Colorado  includes  a section  in their 
training  manual  entitled,  How Not to Give Legal Advice  which provides  a simplified 
judicial  definition  of  legal advice  and relates  the judgement  specifically  to paternity 
acknowledgment  (see Appendix  H) . 
The most important  aspect of these brief  bullet  responses  may be to refer parents  to the 
appropriate  source for answers  to their  questions.  These  documents  are often casual  in 
format:  California  has produced  a document  entitled  Helpful  Advice  to Hospital  Staff 
and several  States produced  documents  of  If.  . . questions  that are informative  and easy 
to read.  Another  value to a Q & A  format  is that it simulates  the exchange  between 
5  hospital  staff and parents.  Even when staff understand  paternity  and their  responsibilities, 
they may be uncomfortable  with the process unless  it is modeled  for them  in some way. 
We received  very  few hospital  staff training  videos,  but one that we did receive  from  New 
Jersey  effectively  used actors to demonstrate  several  typical  staff/parent  exchanges.  A 
few other  States use their  parent  outreach  video  to help train  hospital  staff. 
Training Materials Should AlwaysInclude ContactInformation on Current Child 
Support Staff to Whom PaternityQuestionsMay be Directed or New Training Needs 
Articulated. 
State child  support  agencies  active  in meeting  the needs of their  birthing  hospitals  often 
supplement  their  training  materials  with frequent  direct  contacts  with hospital  staff.  These 
direct  contacts  include  phone  calls,  letters  and on-site  visits,  which vary  with State size 
and child  support  agency  staffing  levels.  Missouri  and Texas,  among others,  conduct 
surveys  of their  birthing  hospitals  (see Appendix  I) to determine  current  training  and 
informational  needs.  When  a hospital  doesnt  respond  to the survey,  it is automatically 
contacted  by the child  support  office  to inquire  about needs or possible  problems.  The 
simplest method  for encouraging  direct  contact  may be to provide  hospital  medical  records 
and obstetrics  departments  with current  addresses  and phone  numbers  of child  support 
field offices  and local  registrars  which distribute  voluntary  acknowledgment  forms  and 
training  materials.  Whenever  possible,  this contact  information  should include  the name 
of a specific  child  support  staff member  familiar  with hospital  needs and procedures. 
Hospitals  are then able to contact  State agencies  based upon  their  own needs and 
convenience. 
HOSPITAL  STAFF  TRAINING  METHODS 
The Effectiveness of Training MaterialsMay be Enhanced by Designing them for 
Informal Use, Recognizing that Much of Staff Training is Ad Hoc and Takes Place 
Withinthe Varied Schedules of HospitalStaff. 
Although  child  support  agencies  may wish that all hospital  staff training  could be highly 
organized  and structured,  reality  dictates  that much of the training  available  to staff is 
very  informal  and ad hoc.  If staff do not happen  to be present  during  a regional  seminar 
or on-site  visit by a child  support agency  worker,  they may hear about the process  by 
word-of-mouth  or be introduced  to the materials  only  when a parent  requests  information. 
Training  then becomes  highly  individual  and dependent  upon the needs,  style and habits  of 
the individual.  Even in States with highly  organized  training  methods,  much of training 
appears to take place within  the routine  schedule  of informing  staff of birth  registration 
methods  and techniques. 
Materials  that were created  to be used in seminars  or in conjunction  with other materials 
may be used alone  and without  explanatory  verbal  instructions.  In creating  hospital  staff 
training  materials,  therefore,  child  support agencies  should recognize  that their  materials 
may be used informally  and construct  them accordingly.  The Illinois  child  support agency 
has attempted  to make all of their  materials  stand alone,  but with cross references  to 
6  each other.  Every  page of their materials  references  the program  name and phone  number 
in case materials  are lost or separated.  A few child  support agencies  have created  a series 
of quick reference  sources such as bookmarks,  magnets  and business  cards to reach 
hospital  staff who may never  review  the training  manual.  These materials  contain  a 
comparatively  small amount  of information,  but may encourage  staff members  to further 
inform  themselves  about the process  and explore  more  formal  training  materials. 
Increased Recognition and Attentionto Training MaterialsCan be Achieved Through 
RepetitiveUse of Familiar Logos, Graphics, Slogans and Acronyms. 
Although  it will  surely  increase  the initial  cost of producing  training  materials,  child 
support  agencies  should consider  paying  for some sort of graphic  design to embellish  all 
of their  hospital  staff training  and parent  outreach  materials.  These  designs  highlight 
paternity  documents  and help distinguish  them from the sea of paperwork  received  by 
medical  records  and obstetrics  departments.  Using an unusual but uniform  color  paper 
may help accomplish  the same objective.  Also in this vein,  creating  a catchy  program 
name or easily  used acronym  is a simple  technique  for effectively  marketing  the paternity 
effort  and increasing  recognition  and repetition  of message.  States should  also make the 
distinction  between  staff training  materials  and parent  outreach  materials  through  the use 
of titles,  graphics  or color.  The child  support  agency  in Florida  has taken pains to label 
each document  clearly  according  to its audience. 
On-Site Visits, Workshopsand Seminars, Which Allow More Personalized Training and 
Interaction Between Agency Personnel and Birthing HospitalStaff, Appear to be More 
Effective. 
Intuitively,  we know that the training  needs of birthing  hospitals  within  the same State 
may be very  different.  One hospital  may have an energetic,  dedicated  birth  registrar  with 
a personal  interest  in the problems  of unmarried  mothers,  while  another  hospital  may have 
frequent  staff turnover  and only  a handful  of nonmarital  births per month.  The closer  ties 
child  support  staff develop  with each hospital,  the more they are able to tailor  their 
training  efforts  to match hospital  needs.  Several  States including  Colorado,  Florida  and 
Illinois  employ  at least one IV-D worker  to travel  from hospital  to hospital  meeting  staff 
and assessing  needs on-site.  These  initial  contacts  are often maintained  by phone  or mail. 
On-site visits may or may not include  formal  instruction  such as workshops,  lectures  or 
seminars.  Our respondents  agree that the key to conducting  these sessions  successfully 
appears to be keeping  them brief  and providing  an open-ended  question  period  which adds 
value to the session by personalizing  the information  received.  Staff should  feel that by 
attending  the session they can learn more  that is relevant  to their particular  hospital  than 
they  would by simply  reading  the written  materials.  Although  not required  by Federal 
mandate,  Montana  and a number  of other  States also offer training  specific  to nurse mid-
wives who operate  outside  of a hospital  setting. 
7 
 HospitalStaff Training ActivitiesAfford an Excellent Opportunityfor  Closer 
CollaborationBetween VitalRecords and Child Support Agencies. 
State vital  records  agencies  often already  conduct  regional  and local training  sessions for 
hospital  birth  registrars,  and in several  States the child  support agency  has requested  time 
during  the sessions  to promote  the acknowledgment  effort  and educate  staff.  Because 
PRWORA  requires  the involvement  of vital records  agencies  in State in-hospital  voluntary 
acknowledgment  programs,  some State registrars  may even be willing  to conduct  the 
training  themselves  or in coordination  with child  support  staff using materials  provided  by 
IV-D.  This method  would take advantage  of the long-term  relationship  between  vital 
records  agencies  and hospital  birth  registrars,  but would  still involve  IV-D because, 
ideally,  hospital  staff should be acquainted  with child  support agency  staff.  This will 
allow IV-D and hospital  staff to begin to build their  own working  relationships  and 
increases  the awareness  of IV-D staff and child  support  issues within  the hospital 
community.  An important  point  to consider  in discussing  any regional  training  efforts  is 
that often only  the principal  hospital  birth  registrar  attends  such sessions.  Although  they 
are certainly  valuable,  regional  training  sessions  are best used in conjunction  with other 
written  and interactive  methods  which are likely  to be useful  to all staff. 
CONNECTING  HOSPITAL  ASSESSMENTS  TO  STAFF  TRAINING 
Adapting Staff Training Materialsto HospitalAssessment OutcomesMay Allow State 
Child Support Agencies to More Fairly and Accurately Evaluate Birthing Hospital 
Program Participation. 
Although  OBRA only  requires  that child  support  agencies  monitor  the program 
participation  of birthing  hospitals  by comparing  the number  of acknowledgments  a hospital 
receives  to their  total  number  of nonmarital  births,  a few States have begun to assess 
hospital procedures as well as outcomes.  Examples  of potential  assessment  criteria 
include  hospital  staff contact  with unmarried  parents,  documentation  handling,  and even 
use of staff training  and parent  outreach  materials. 
If States are to truly  evaluate  hospital  participation,  they  must communicate  clear  outcome 
expectations  and must make sure that hospitals  understand  those expectations.  Hospital 
staff training  can be used effectively  for this purpose.  Both New Jersey  and 
Massachusetts  clearly  coordinated  its staff training  efforts  with future assessment 
procedures.  Its staff manual  is structured  as a set of objectives  (see Appendix  J) with 
specific  instructions  following  each goal.  Objectives  include  the receipt  of more  signed 
acknowledgments  but also address actions  which may  lead to a higher  acknowledgment 
rate,  such as wide distribution  of materials  and structured  internal  training  of new staff. 
8 
 Linking Staff Training and HospitalAssessment Provides a Framework Within Which 
the Child Support Agency May Address Any Problems of HospitalNoncompliance. 
Because many  States consider  themselves  too early  in implementation  to require  hospital 
compliance  or are not yet aware of which  hospitals  are truly  participating,  the issue of 
hospital  noncompliance  has not yet been widely  addressed.  Once program  implementation 
is Statewide,  child  support agencies  must not only  effectively  monitor  hospital 
participation  but must also prepare  policies  and procedures  for dealing  with hospitals 
which do not meet their program  objectives.  State child  support offices  may be better 
able to describe  and address deficiencies  in hospital  participation  if they can refer  to a 
performance  framework  established  during  hospital  training.  Writing  training  materials 
and curriculum  with overall  program  objectives  in mind allows the staff training  and 
hospital  assessment  procedures  to complement  each other. 
9 
 CONCLUSIONS 
Although  many  States are still early  in their  implementation  of in-hospital  voluntary 
paternity  acknowledgment  programs,  a number  of State child  support  agencies  have made 
great strides  in addressing  the needs of birthing  hospital  staff as they communicate  with 
unmarried  parents  and aid in the documentation  of acknowledgment.  Based upon our 
analysis  of the materials  and practices  reviewed  in this report,  we draw the following 
conclusions  about State efforts  to educate birthing  hospital  staff about voluntary  paternity 
acknowledgment  programs: 
SIMPLICITY OF MESSAGE.  VoluntaryAcknowledgmentMaterials That are Simple 
and StraightforwardBest Suit the Busy Schedules of Obstetricsand Medical Records 
Staff. 
Hospital  staff must inform  new parents  about many  health-related  topics  and often have 
little time to cover  paternity  instructions.  Therefore,  hospital  staff training  materials  must 
be simple to use.  One method  is to create  brief  materials  which  include  only  the most 
crucial  instructions  and information  and supplement  these snapshots  with more detailed 
materials  to be used as needed. 
USE OF MULTIPLE  METHODS.  Use of Multiple Training Methods Helps Ensure a 
Clear and RepetitiveMessage Reaches All Varieties of HospitalEnvironments. 
Regardless  of the primary  methods  used,  all highly  proactive  States employ  a wide variety 
of mediums,  methods  and techniques  for carrying  their message.  The same States which 
had produced  thorough  training  manuals  were also likely  to have created  brief  brochures, 
videos and posters  which conveyed  the same message using similar  graphics,  acronyms 
and slogans. 
FOLLOW-UP AND PERSONAL CONTACT.  Training Materialsare Unlikelyto Be 
Effective WithoutDirect Contactby State Child Support Staff. 
The closer  ties child  support  staff develop  with each hospital,  the more  likely  they are to 
tailor  their  training  to match hospital  needs.  Materials  may not be used effectively  or at 
all when they have been received  with no personal  contact,  verbal  explanation  or 
interaction.  Also,  direct  contact  through  on-site  visits can help to build relationships 
between child  support agencies  and hospital  staff and lead to better resolution  of any 
future issues. 
TRAINING TIED TO ASSESSMENT.  ConsiderationShould Be Given to Future 
Assessment of HospitalParticipationWhen Creating Staff Training Materials. 
If  States are to truly  assess and evaluate  hospital  participation,  they must communicate 
clear outcome  expectations  and make  sure hospitals  understand  those expectations.  This 
could be accomplished  by clearly  coordinating  staff training  efforts  with hospital 
assessment  criteria  and procedures. 
10  AGENCY  COMMENTS 
We have worked  in close partnership  with OCSE throughout  the conduct  of this 

inspection.  Although  we did not receive  formal  comments  from  ACF on our draft 

reports,  they  demonstrated  through  their  collaboration  a general  agreement  with this report 

and the companion  reports.  We worked  with OCSE in developing  a research 

methodology,  provided  extensive  briefings  on study findings  and created  additional 

documents  to meet agency  needs.  We appreciate  their  cooperation  and guidance,  and will 

continue  to work with them on the issues raised  in these reports. 

11 
 Ar,Pendix  A:  Staff  Fact  Sheets 
HOSPITALS  CAN HELP CHILDtiN  AND THEMSELVES  BY PARTICIPATING  IN 
MISSOURIS  PATERNITY  ESTABLISHMENT  PROGRAM 
FACTS 

29.5% of the children born in the United States during 1991 were bJrn out of wedlock. 

 
32.5% of the children born in Missouri during 1994 were born out of wedlock. 

 
66% of young, unwed fathers are present at the births of their children. 

 
80% of young, unwed parents feel it is important for fathers names to be on babies birth 

 
certificates. 
I 
DCSE NEEDS YOUR HELP.  Last year, 23,845 children were born out-of-wedlock  in 
Mkouri.  Children raised in single-parent  households are far more likely to live in poverty than 
children raised in married couple homes.  Many children living in poverty are recipients of Aid 
to Families  With Dependent Children  (AFDC).  Proposed federal legislation  will limit the length 
of time a family can receive AFDC.  What will happen to children when this assistance ends? 
More than ever, children will need the support of both parents. 
HOW  CAN YOU HELP?  The Bureau of Vital Records (BVR) provides you with a form, 
Aflakvit  to Add Fathers Name to the Birth Record of a Child Born in Missouri Out of Lawfir 
Wea%&  The Division  of Child Support Enforcement  (DOSE) provides you with a pamphlet, 
What It Means to Establish Paternity for  Your Baby.  Missouri law requires designated  hospital 
staffto  provide the pamphlet  and the paternity  aflidavit  to unmarried  parents so they may 
~~btarily  acknowledge  paternity  of their child.  When the parents sign the paternity  affidavit, 
the fithers  name is added to the childs birth certifkate  and a presumption  of paternity  is 
created.  Once there is a presumption  of paternity,  DCSE can establish child support akd health 
insmmx  obligations. 
The younger the child, the more likely  it is that the father will sign a patemity  affidavit.  YOUcan 
make a dramatic impact on the paternity  establishment  rate in Missouri if you: 
  unmamedparents with the pamphlet,  What it Means to Establish Patem@  for 
Baby. 
 
Offer BVRs paternity  affidavit  to the unmarried  parents of children  born in your hospital. 
 
~vetbe~~accesstoyournotatiessothattheaffidavitcanbesignedandnotarized 
 
whilethemothaandthebabyarestillinthehospital. 
lnformunwtd~~l~thatifeitherpersonisunsureaboutwhothefatheris,M=SEcan 
 
mmgefMi-eegcnetictcsting. 
WHY SHOULD YOU HELP?  DCSE knows you are busy.  You dont have a lot of time for 
extra paperwork and hassles.  But by participating  in Missouris  paternity  establishment 
program, you will help yourselves  in the long mn.  DCSE has a legal mandate to establish  and 
enforce health kurance  obligations  for children.  A health insurance  obligation  cannot  be 
aWed  until paternity  is established.  Please help DCSE md yourselves  by working  together  to 
establish paternity  for Missouris  children. 
a  - 1  NEW  JERSEY  FATERNITY  OPPORTUNFiY  PROGRAM 

PREVENTING  CHILDHOOD  POVERIY 
WHY  HEXLj7-f  CARE  PROVIDERS  SHOULD  CARE  ASOUT 
PAERNIJY  ACKNO  WLEDGMENT 
What is the New Jersey Paternity  Opportunity  Program? 
It is a hospital-based paternity acknowledgment program that providesunmamed couples the opportunity 
to acknowledge their childspaternity w  when the child is born. The purpose of the Program is to 
help unmarried fathers establish a legal relationship with their children. 
Why should  hospitals  participate  in this Program? 
FACE 	 In 1993, the number of children born to unmarried parents in the United States    
soared to an all-time high - 31% of all births. In New Jersey in 1994,28.4%  of all 
births in the state were to unmarried parents. 
FACE  : 	 Chitdren raised in female single-parent households are farmore  likely to live in 
poverty than children raised in married couple homes.  In 1991, the poverty rate 
for children living in female headed homes was 55.5%, compared to a poverty rate 
of 10.6% for chikfren in married-couple homes. 
FACT= :  In 1992,68%  of AFDC children were in families with never-married mothers. 
FACT: 	 Unwed mothers are less likely to receive child support than divorced, 
separated, of remarried mothers. Only 14.5% of unwed mothers receive 
,chii  support, compared to 31% of separated mothers, 64% of divorced 
mothers, and 48% or remarried mothers. 
FACT:  The chances of establishing a childs paternity decrease as the child gets older. 
A-2 
 WHY  IS  PATERNIIY  ESTABLISHMENT  IMPORTANT? 

Paternity  Establishment  Provides  The  Following  Benefits: 
Relationship 	 It is important  for a child to know his or her mother and father and benefit 
from a relationship  with both parents.  Once a legal relationship  is 
established  with the father, the father is more likely to maintain his own 
relationship  with his child. 
Identity  The fathers information will appear on the childs birth certificate. 
Medical 	 The child will have information about both parents medical histories. This 
is especially important if the child inherits a medical problem from one of 
the parents. 
Custody and  With legal paternity established, the father can request visitation rights and ask for 
Visitation  a share in custody arrangements. 
Adoption 	 The father gains the right to have a say in any plans to have the child 
adopted by someone else. 
Benefits 	 The child oan qualify for benefits from both parents including social 
security, health and Tie insurance, inheritance rights, veterans benefits, 
and others. 
support 	 Both parents have a responsibilityto support the child. This indudes 
financial as well as emotional support  If the parents choose to separate 
and paternity is already decided, it is easier for the mother to obtain -child 
support from the father. 
How Does The Program Work? 
Hospitals provide unmarried mothers with information about paternity aoknowtedgment.  tf parents want to 
establish paternity, they fill out the CerfRare  of Parentage.  Both patents sign the Cerfkare  in the 
presence of a witness on the hospitals staff.  If the mother is married but her husband is not the father of 
the child, the mother and her husband can complete an Affidavit of Denial of &fern@  to keep the 
husbands name off the Birth &t&ate.  This Denial allows the mother and father to complete the 
Q?rtificateof Parentage to add the true fathers name to the birth oertifioate. 
A-3 
 Amendix  B:  Consequences  Flow  Chart 
KUdTtUPPENS  HW.ENPATERNITYLTNOTESTABUSHED? 
When a child is born out-of-wedlock at the hospital, 
patmityisnotestablishcd(thebabydounothave 
a legal htkr). 
I 
/  / 
.~ombecoa#soneoftheincregsinemlmbefsof 
poor, single-parent households. 
/ 
9  v
/  /  /  / 
Mom may apply for public assiam,  3r she may voluntuily init&te 
child support services. 
c, 
v 
/  /  V 
/ 
AFDC recipients are automatiCally I 
atmitynmstbee3tabii&edb&m 
entitled to child support javices. 
childsupportcanbcordued. 
J 
The Child Support Divisiontries to 
~1ocatedadandescabiiahpaternity 
sotbm%dsuppmcanbeordcred 
! 
II-1 
 Ar,Pendix  C:  Instruction  Sheets 
STATEClf~wlylM  ml 
oMo(Q-amwaB  to1 
oR*E~cMDsIppoRT 
PATERNITY ESTABLISHMENT 
INSTRUCTIONS  FOR MIDWIVES 
Immediately preceding orfofiowing a birth that was attended by a midwife, when the mother is not married, the midwife 
must take the following steps: 
MaotwiththemotlmrandaIbgodtather. 
1.  Confirm that they were not married at the time of either concqtion  or birth or anytime 
conce@nandbfrth.  Ifthemothetwasmaniedknclaimsthatherhusbandisnotthefather, 
seethesectionontheback: 
wtmnthamodl#rknunMbuthuhllsbJdknotfiwchws 
mhu. 
2.  Give the motherthe  booklet entftleEds:ta6kd-1  Paternrt~,  Cw YOGTChtb.3S&d 
-MonlsusuaflyAslt,andThf?irAnsw!ers.= 
3. 	 Give the alleged faWrthe  bookfet entitkd:  Estob  bh  Patermt~,  for  YOW-Chrzds So&d 
~DadsusuauyAsk,andTheirAnswers. 
0  Folbw~1,3,4,5,7,and8. 
manbaehpmNntaatgnanAmdmraot~,thomtduttamud: 
0  mduBsuretheparemtshnvethoW@fy~theAffidavitofPatemity; 
0  makesltluaasignahrr#arenolark~: 
0  compktesedorlVoftheAffkja~ofPatemfty; 
0  givethepinkcopyoftheAfMmdtdPaWrnitytothefather; 
(a  #VERSE) 
C-l  page2 
When both parents sign an Affidavit of Paternity the midwife must (contd from Page 1): 
0  give  the gold copy of the Affidavit  of Paternity  to the mother; 
  mail the original  Affiiavit  of Paternity  (white copy) to the clerk of the city or town where the child was 
born with  the birth certnicate; 
I 
0  complete  Form, 699, Bill for Affidavit  of Paternity;  C-S-122 16.951  ARIZONA DEPARTMENT OF EC012;OMIC5ECCRlTY 
INSTRUCTIONS  FOR  HOSPITAL  STAFF  FOR  THE  COMPLETION  OF 
THE ACKNOWLEDGMENTOF PATERNITY  PACKET 
The following information addresses your role in offering the Acknowledgment of F%..ty  packet to unmarried parents. If you 
have further qUC.stionsp,lease call the Hospital Paternity Program office at (602) 274-8235 
1. 	F%.u  distribute the Acknowledgment packet to unmarried parents as soon a.~possible after admission 10 the h~sp~~  and 
encourage them to read a(1of the information provided. 
2. 	 Coofii  that the parents v  other when rhe child was born and rhuxufb*V  a[ 
the time of birth or any time in the ten months immediately preceding the buth. 
3. 	 The Acknowledgment form does not have to be tYped, If the parents fill II out themselves, please ask them IOpMt  clearly  and 
press hard enough to make the copies. Remind them to use BLACKINK. 
4. 	 Check that all sections on the forms are completed. For example, if a parent is unemployed, None should be put III be 
employer bOX. The parents should complete the occupation section with their usual occupation. If a mother is on AHCCCS 
iostcad Of insUraoCe,put her AHCCCS number in the section for the insurance policy number. 
5. 	 For a newborn child, the DHS copy of the  and notarized Ackwwledgmen~ must be submirted with rhe original blnh 
completed 
c&ficate.  The fathers name should be shown on the birth certificate. Remember, this process can only be used if the morher 
is IlQtmarried and both pvenU  have signed the Acknowledgment. 
6.  I&oiga  Ac~ledgment,  both the yellow sod pink copies, must be sent to: 
Division of Child Support Enforcement 

Hospital PaternityProgram 

PoBox33460 

Pbocoix. AZ 85067 

PlclscwCtbCUkkdSCd envelopes provided. 
7. 	 If w  m  culls  sign the Acknowledgment before the submittal of the birth certificate,  they rmy sign it a1a later date. 
arc  are inMlaiollr  011tbc Acknowledgmentform that explain the mail-in ~~OC&UCI.f parentswrdt to establishpaterxuq 
for Older  children.  @USC  provide them with  additional  packets  &  instruct  &cm  to follow  the mail-h  ~~ISUUC~~OOS00 the back 
0fthcAcknowkdgmaufonn. 
8.  Ifpuatssbouks&et&o  ordadtrbout~tbcA~w~td~,doedprauretbcmtomnkea 
qp#r  dc!&bo* WY  slstldd be @vc!awhatever time they M!d to taut to tklr  amtmey(s),  to think about it, or to I+ 
. 
-~-fhlmtkDivIsiouofch8dsupportEnf~,  ~orpiw  htedty  lmgmm office.  Remind 
~~yoo-~tbsQkgBI~. 
c-3  Appendix  D:  Reminder  Checklist 

NEW  JERSEY  PATERNITY  OPPORJUNITY  PROGRAM 

HOSPITAL  CHECKLIST 
Cl 
Mother  given  packet  containing  Certificate  of Parenfage,  Affidavit  of Denial of Paternity, brochures, 
and genetic  testing  information  form. 
0 

Each completed  form is either  printed  in blue  or black  ink. 
0 

Every item on each form is filled in, including  the names,  addresses,  parent  signatures,  social 
security  numbers,  and witness  signatures. 
cl 
Social  security  numbers  were corlected  from each parent  and filled in on the form(s).  If the parent 
does  not have a social security  number,  a brief explanation  is provided  in the social security 
number  space  or at the bottom  of the form. 
0 

Both parents  signed  the certificate of Parentage  and had their signatures  witnessed  or notarized.
0 

Both the mother  and the father  initialed  the Rights  and Responsibilities  on the back of the form. 
0 

Both the mother  and her husband  signed  the AfMwit  of Denial of Paternity and had their 
signatures  witnessed  or notarized. 
0 

The form is filled out in English,  even if read in another  language. 
0 

Information  provided  on the form is identical  to that provided  on the birth certificate. 
D-l  Appendix  E:  Roles  of  Key  Players 

T  ogether  E  veiyone A  thieves  M  ore 
PUBLIC HEALTH 
- provide affidavit form 
-	 prywideinformation on rights 
responsibilities 
- p&de  assistance and training 
SOCIAL 

HOSPITALS 

3ER\IICES 
educate and sell  fi  3- 
assist unwed parent5 in 
Importance of  3  establishing paternity 

- forward completed affidavit 

paternity establishment 
answer techn.ical  and birth certificate 

questions 

assist with child 
support orders 

PUBLICXEALTH 
- register birth certificate and affidavit 
- record patern@ affidavit 
-	 provide informAtionto DSS for child 
SUPpI  pupodes 
TOGETHER  wE  CAN HELP A CHILD!!! 
E-l  Introduction 
I 
The  New  Jersey  Paternity  Opportun-t-ty- -P--r7o gram
J  Purpose of the  Paternity  Opportunity  Program 
The Paternity  Opportunity  Program  is designed to help a chiid of unmarried  parents  establish  a 
legal relationship  with his or her father.  The Program was conceived  (no pun intended!)  by 
the State of New Jersey,  in response  to a federal mandate,  to make it easier  for parents  to 
acknowledge  paternity  voluntarily  using simple in-hospita!  processes  at the tune  of birth.  The 
Paternity  Opportunity  Program  (POP) builds upon existing processes  that enable  unmarried 
parents to add the fathers  information  to the childs birth certificate. 
J  Goals of the  New  Jersey  Program 
The Paternity  Opportunity  Program  has the potential  to increase the number  of legal paternity 
establishments  for children  born to unmarried  parents.  The Program  is designed  to accomplish 
the foliowing  objectives: 
b 	 Enhance the voluntary  paternity  process that has operated  in conjunction  with the 
States birth registration  process; 
b 	 Encourage parents who are not married  to each other to acknowledge  paternity 
voluntarily; 
b 	 Obtain the benefits of paternity establishment for increased numbers of children of 
unmankd  parerits; and 
.  Improve the self-sufficiency of unwed mothers and reduce welfare costs. 
J  The Hospitals  Role in Paternity Establishment 
New Jerseys birthing hospitals piay a critical role in the success of the patemitj 
acknowledgmentprocess.  Under the law, hospitals rrmsfprovide urunarried motherswiththe 
forms and information necessary to acknowledge paternity voluntarily.  Fortunately,. the 
E-2 
 Introduction 
hospitals already  have effective  procedures  in place for collecting  birth  information  and 
processing  birth  records.  Hospitals  contribute  to the paternity  acknowledgment  process  by: 
b 	 Presenting  mothers  and fathers  who are not married  to each other  with the opportunity 
to acknowledge  paternity  voluntarily  when their child  is born; 
b 	 Providing  the parents  with informational  materials  to help them understand  what 
paternity  acknowledgment  can mean to them and to their child;  and 
b 	 Ensuring  that the signed  paternity  forms are processed  correctly  so that information 
about the father  of the child  is placed on the birth  certificate. 
J  The  Local  Registrars  Role in Paternity  Establishment 
New Jerseys  local  registrars  also play  an important role  in the success of the Paternity 
Opportunity  Program.  Local  registrars  contribute  to the program  by: 
b 	 Presenting  mothers  and fathers  who are not married  to each other  with the opportunity 
to acknowledge  paternity  after  the birth is recorded  using the Certificate  of Parentage 
form; and 
b 	 Providing  the parents  with  informational  materials  that will help them understand  what 
paternity  acknowledgment  means  for them and their child. 
The  Department  of  Healths  Role in Paternity  Establishment 
The Department  of Health  is responsible  for overall  coordination  and administration  of the 
States birth registration  process.  Specific  roles related to the paternity  acknowledgment 
process include: 
b 	 Contributing  to the development  of standards and instructions  for completing  patemity
related  forms; 
E-3 
 Introduction 
b 	 Maintaining  the States Electronic  Birth Certificate  (EBC) system which allows 
hospitals  to generate  birth  certificates  and Certificatesof Parenrage (Parentage forms) 
electronically;  and 
b  Providing  data regarding  paternity  status and hospital  performance. 
The  Office  of  Child  Support  and Paternity  Programs  Role in 
Paternity  Establishment 
The Office of Child  Support  and Paternity  Programs  (OCSPP) provides  assistance  to parents 
who wish to establish  the paternity  of their  children  and collect  child  support  from an absent 
parent.  Under  federal  and state law,  OCSPP is charged  with implementing  a simple process 
for unmarried  parents  to acknowledge  paternity  volur&&  without  going  to court. 
OCSPP is a strong  supporter  of the process  in New Jersey  that has allowed  unmarried  parents 
to add the biological  fathers  information  to a childs birth certificate  in the hospital  or local 
registrars  office.  OCSPP will also coordinate  the development  of brochures,  video  tapes,  and 
other educational  materials  to make unmarried  parents  aware of their  option  to acknowledge 
paternity  and the importance  of paternity  acknowledgment  to children. 
J  How  Paternity  Acknowledgment  Works 
Under the former  process  of signing  the back of the birth certificate,  New Jersey  allowed 
unmarried  parents  to add the biological  fathers  information  to the childs  birth  certificate. 
With the new Parentage  form,  the process  goes a significant  step further  by creating  a binding 
establishment  of paternity.  This means that ome the parents  sign the Parentage  form,  the law 
specifies  that the man who signs the form  is the legal father. 
J 
Married  Mothers  and Their  Husbands  (Presumed  Fathers) 
What  is a Presumed  Father? 
Under the law,  if a married  woman  gives birth,  her husband  is presumed  to be the father 
(presumed  father)  of the child.  This  is called a legal presumption  of paternity. 
E-4 
 Appendix  F:  Affidavit  Instructions 
HOW  TO COMPLETE  THE FORMS 
Affirmation  of Paternity,  Form  JD-FM-145  (Hospital),  Page  2 of 2 
Kev No.  Exnlanation 
1  Docket  Number  - This  number  is entered  by the court  clerk. 
2 	 Plaintiff  - The  plaintiff  will  be the mother.  Enter  her name  the  same  as 
her  signature.  See #5, #13, and  #15. 
3 	 Defendant  - the  defendant  is the  father.  Enter  his name  as it appears  on 
the  Acknowledgment  of Paternity. 
4 	 Superior  Court  - Do not  enter  anything  here.  Hospitals  are not expected 
to file the completed  acknowledgments  with  the appropriate  court  clerk, 
but  instead  will  forward  them  to DSS  for filing.  DSS  will  determine 
the proper  court  in which  to file  the acknowledgment. 
Enter  the mothers  name.  Make  sure the name  is entered  exactly  the 
same  as her signature.  For example,  if the mother  goes  by the name 
Pat,  but signs  her  name  as Patricia,  enter  Patricia  here. 
6  Enter  the mothers  town  of residence. 
7  Enter  the mothers  county  of residence. 
8 	 Enter  the fathers  name  as it appears  on the Acknowledgment  and in #3, 
above. 
9  Enter  the complete  address  of the father  if known  by the mother. 
10 	 Enter the  full name  of the child.  For multiple  births  the names  of up to 
four  children  may  be entered  on the same  afIirmation  form. 
11  Enter the childs  date of birth. 
12 	 Enter  the town  and state of the  childs  birth,  i.e.,  the town  the hospital 
is in. 
13 	 The mother  signs  here,  in ink,  exactly  as you  have  entered  her name  on 
lines  #2, #5, and  #15. 
14 	 Enter  the date  the affirmation  is signed,  for example,  On this 23rd  day 
of October,  1995,.  The  Affbmation  and the Acknowledgment  do not 
have to be signed  on the same  date. 
F- 1  Appendix  G:  Parent  Q  &  A 
TRANSLATEDMATERIALS 
The forms ate being translated  into languages  in addition  to Spanish.  A package of one copy of 
each form in multiple languages  will be mailed to all hospitals.  If you have any questions about 
the translated  forms,  please  call Jim Mullany,  Office of Child  Support,  at (916) 654-1223. 
ANSWERS  TO YOUR  QUESTIONS 
1) 	 Q  What  if one parent wantsto sign the Dedarafion of Paternityand the other parent 
does not? 
A 	 If only  one parent  wants to sign the form,  it should not be accepted or processed 
by the  hospital.  The form  must be completed  and signed by both parents  to be 
considered  valid.  The program  is voluntary  on the part of both parents. 
Q  What if the parents do not want to provide  all of the information  requested on the 
2) 	
Declaration of Patemiq form? 
A 	 Parents who wish to voluntarily  declare paternity  using the declaration  form must 
provide  all  the  information  requested  except  their  Social  Security  numbers. 
Providing  Social  Security  numbers is the only  optional  information  on the form. 
3)  Q  Can minor parents  complete  and sign the Declaration of Paternity? 
A 	 Yes.  Minor parents may complete and sign a Declaration of Paternity. However, 
other laws and the court will determine  if the declaration  may be used to establish 
paternity. 
4) 	 Q  Is the copy  of the Deciizrationof Paternityretained  by the hospital  considered  to 
be a medical  record? 
A 	 No.  The  copy  of the Declaration of Parer&y retained by the hospital  is not a 
medical record.  The copy is for hospital  administrative  use, including  processing 
the $10 payment. 
5) 	 Q  If  the  parents  return  to  the  hospital  after  the  mother  and  baby  have  been 
discharged,  are hospital  staff required  to accept and process  the form? 
A 	 No.  It is recommended that hospitals accept and process  the forms  submitted prior 
to the time the birth  certificate  is transmitted  to the local deputy registrar  of Vital 
Statistics. This is normally five to 10 days following  the birth of the child.  Parents 
wishing  to complete  a De&ration  of Patemiryafter  the hospital  has transmitted 
the birth  certificate  should be directed to the local Family  Support  Office. 
G-l  Appendix  G:  Parent  Q  &  A 
TRANSLATEDMATERIALS 
The forms are being translated  into languages  in addition  to Spanish.  A package  of one copy of 
each form in multiple languages  will be mailed to all hospitals.  If you have any questions about 
the translated  forms,  please  call Jim Mullany,  Office of Child  Support,  at (916) 654-1223. 
ANSWERS TO YOUR QUESTIONS 
1) 	 Q  What  if one parent wantsto sign the Dedaration of Paternityand the other parent 
does not? 
A 	 If only  one parent  wants to sign the form,  it should not be accepted or processed 
by the  hospital.  The form  must be completed  and signed by both parents  to be 
considered  valid.  The program  is voluntary  on the part of both parents. 
Q  What if the parents do not want to provide  all of the information  requested on the 
2) 	
Declaration of Paternityform? 
A 	 Parents who wish to voluntarily  declare paternity  using the declaration  form must 
provide  all  the  information  requested  except  their  Social  Security  numbers. 
Providing  Social  Security  numbers is the only  optional  information  on the form. 
3)  Q  Can minor parents  complete  and sign the Declaration of Paternity? 
A 	 Yes.  Minor parents may complete and sign a Declaration of Paternity. However, 
other laws and the court will determine  if the declaration  may be used to establish 
paternity. 
4) 	 Q  Is the copy  of the Declaration of Paternityretained  by the hospital  considered  to 
be a medical  record? 
A 	 No.  The  copy  of the Declaration of Paternityretained by the hospital  is not a 
medical record.  The copy is for hospital administrative  use, including  processing 
the $10 payment. 
5) 	 Q  If  the  parents  return  to  the  hospital  after  the  mother  and  baby  have  been 
discharged,  are hospital  staff required  to accept and process  the form? 
A 	 No.  It is recommended that hospitals accept and process  the forms  submitted prior 
to the time the birth  certificate  is transmitted  to the local deputy registrar  of Vital 
Statistics. This is normally five to 10 days following  the birth  of the child.  Parents 
wishing  to complete  a Declarationof Paternityafter  the hospital  has transmitted 
the birth  certificate  should be directed to the local  Family  Support Offtce. 
G-l  Appendix  H:  Leeal  Advice 
C.  How not to give legal advice 
When discussing  paternity with patients you will sometimes  be asked questions  that are 
of a legal nature, which could put you in the position of giving legal advice.  Offering legal 
advice  is  reserved  for  attorneys.  The  first  step  in  avoiding  this is  acquiring  some 
understanding  as to what  constitutes  legal advice.  To quote  from  the Colorado  Bar 
Assn.  Ethics  Committee  Ooinions.  Formal Opinion  No. 79:  Use of  Legal Assistants  in 
Client  ReDresentation  at Hearinas.  Deoositions  or Administrative  Proceedinas  Adopted 
Februan,  18. 1989  (see appendix J). Generally,when one  acts in  a representative 
capacity  in protecting,  enforcing  or defending  legal rights  and duties  of another  and in 
counseling, advising and  assisting in connection with such  rights and  duties, such 
conduct  constitutes  the practice  of law. Denver Bar Assoc. v. Public UtilitiesComm., 
154 COIO. 273, 391 P.2d 467 (1964).  Unauthorized Practice of LavvCommittee V. Prog, 
761 p.2d 1111 (Cola.  1988). This definitiongives some guidance on what the courts have 
determined is the practice of law, and the final determination remains with the courts. 
It is recommended  that parents with in-depth questions be  referred to  the  literature 
provided  by the Colorado Department of Social Services.  When question arise that are 
outside of the answers provided in these pamphlets, it is suggested that you contact the 
county hospital liaisonor refer the patient to an attorney of their choosing. 
Experience  has  shown  that  parents  with technical legal  questionls are  resistant to 
voluntarilysigning a Statement of Paternityand should therefore be referred to a lawyer 
or the countyChild SupportOfice. 
H- 1 
 Appendix  I:  Hospital  Needs  Survey 
Hospital Survey 
1. 	 How many  staff are designated  to offer  the acknowledgmsnt  fxrr:   Vv%atis the nature of the 
staffs  position  (nurse,  medical  records,  social  worker)? 
2. 	 At what point during the mothers stay are the acknowledgment  form and pamphlet 
provided? 
3. 	 Are the staffwho  provide the acknowledgment  form to the parent(s) also responsible  for 
completing  the birth certificate? 
4. 	 Does the hospital have any problems with notary availability?  Would it be beneficial to have 
additi0r.d  notaries? 
5. 	 Would in-service training regarding paternity acknowledgments  be beneficial for hospital 
StafI? 
6. 	 Do you facl the pamphlet  is appropriate  and provides necessary information(is  the reading 
level too diflicult,  does it adequately address the parents concerns)? What suggestions  would 
you make for improvement? 
7. 	 Do you fkcl that  is a need for bdditiouai educational  materi&  in the hospital (e.g., 
panphla  video, second language xnateds,  etc.)? 
8. 	 What ptnxntage  of the &hers  would you e&mate  are present during some point of the 
mothers stay for out-of-wedlock  bii? 
,9. 	 wbar  parents choose not to achnowlaigt  ptcrnity,  do they provide any reason for making 
this choice? If so, what reasons do you hear most iiequcntly? 
IQ.What is the most significant problem you (or your staff) have encountered  with the 
implcmcntation  of this program? 
.  . 
11. What can DCSE do to assist your staff with the in-hospital paternity acknowledgment 
Fm-9 
I- 1  Volunteers  in Paternity  (VIP) 
HospitaLBased  Paternity  Program  Survey 
1997 
We appreciate  the time you  are taking  to fill out this brief  questionnaire.  The  information 
that  we collect  from  these  surveys  will  help  us assess the progress  and  demands  of our 
program.  Please  return  this  survey  by Tuesday,  March  17, 1997.  Thank  you  for your  help, 
and  feel free to contact  us if you  have  any  questions.  We have  included  a Volunteers  in 
Paternity  (VIP)  contact  list for your  convenience. 
General  Information: 
Name  of hospitaI/healthcare  facility: 
Phone:  Ext. 
Address: 
City:  State:  Zip 
Name  of hospital/healthcare  facility  staff person  responsible  for distributing  hospital-based 

paternity  information: 

Name  of HospitaUhealthcare  facility  Chief  Executive  Officer 

Please  estimate  how  many  births  your  facility  has in one  month 

Please  estimate  how  many  of those  births  are out  of wedlock 

Propram  Operation: 
1. Name  of department  responsible  for distributing  paternity  pamphlets  to new parents 
2. Name  of department  responsible  for giving  new  parents  the  opportunity  to acknowledge. 
paternity  for their  baby 
3. Has this department  been  in charge  of distributing  this information  since the beginning  of the 
Volunteers  in Paternity  Program? 
Yes -- 
NO-
4. 	 Has  there  been  significanr  staff  turncver  since  the  \olunteers  in  Paternity  training? 
Yes  __ 
x0  .__-
I-2 
 Appendix  J:  Program  Objectives 

Overview  of  Paternity  Acknowledgment  Process 
Hospitals  are responsible  for giving  parents who are not married  to each other  tie  opportunity 
COestablish paternity  legally.  Hospitals  also need to educate unmarried  parents  about paternity 
acknowledgment  and availability  of child suppon  by making  available  printed  materials  and 
videotapes.  TO establish  paternity  at the time of birth,  parents  must complete  the Cenifcate  of 
Parenrage  (Parentage  form).  The hospitals  role is to ensure  that unmarried  parents  have 
every Opportunity to complete  this form.  To fulfill this role,  hospitals  must: 
.  inform parents  not married  to each other of their option  to acknowledge  paternity; 
.  provide  the parents  with a packet of information  about paternity  establishment;  and 
.  ensure the availability  of a witness or notary public  so that the form can be completed 
in the hospital. 
The Parentage  form  collects  much of the same information  as the birth certificate  and in most 
cases the information  on the two documents  must match.  Consequently,  hospitals  should 
process the Parentage  forms  along  with the birth certificates.  Beginning  in 1995, all hospitals 
will have the chance  to install  the New Jersey Ele:tronic  Birth Certificate  (EBC),,syStem. 
Hospitals that use the EBC will have the ability to produce  the Parenrage forms  electronically 
along with the birth  certificates.  This  will streamline  the preparation  and processing  of the 
Parentage  forms. 
GENERAL GUIDELINES 
The following  guidelines  to the paternity  acknowledgment  process  provide  ydu with some 
important  things to remember. 
J-I