Department  of Health  and  Human  Services 
OFFICE  OF 

INSPECTOR  GENERAL 

IN-HOSPITAL  VOLUNTARY  PATERNITY 

ACKNOWLEDGMENT  PROGRAM 

State  Agency  and  Birthing  Hospital  Implementation 
JUNE  GIBBS BROWN 
Inspector  General 
AUGUST  1997 
OEI-06-95-00160  OFFICE  OF INSPECTOR  GENERAL 
The mission of the Office of Inspector  General (OIG), as mandated by Public Law 95-452, 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 
 Arm OConnor,  Program  Specialist 

Michelle  Adams,  Ph.D 
 Linda Moscoe 

Karen Erickson,  Intern 
 Barbara Tedesco 

Lisa Lesh,  Intern 

Marnette  Robertson 

Sarah Taylor 

Nancy Watts 

For additional  copies of this report,  please contact the Dallas Regional  Office at (800) 848-8960.  Department  of Health  and  Human  Services 
OFFICE  OF 

INSPECTOR  GENERAL 

IN-HOSPITAL  VOLUNTARY  PATERNITY 

ACKNOWLEDGMENT  PROGRAM 

State  Agency  and  Birthing  Hospital  Implementation 
JUNE  GIBBS  BROWN 
Inspector  General 
AUGUST  1997 
OEI-06-95-00160  EXECUTIVE  SUMMARY 

PURPOSE 
This report  describes  State implementation  of in-hospital  voluntary  paternity 
acknowledgment  programs. 
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.  Many  States have long used hospital-based  programs, 
and even now the voluntary  acknowledgment  process  may be administered  largely  at State 
discretion,  but the intent of the Federal  mandates  is to make paternity  acknowledgment 
part of the birth  registration  process.  Therefore,  State child  support and vital  records 
agencies  are in the process  of forging  new or enhanced  working  relationships. 
Comprehensive  mail  surveys  were completed  by both child  support and vital  records 
agencies  in every  State and the District  of Columbia.  In the child  support agency  surveys, 
we focused  on contact  with hospitals  and procedures  for acquiring  completed 
acknowledgments.  For vital records  agencies,  our focus was on paternity  documentation, 
but also covered  interaction  with child  support  offices,  outreach  to hospital  staff and State 
laws governing  the use of birth  registry  information. 
FINDINGS 
All States have established  in-hospital  programs  for voluntary  paternity  acknowledgment, 

although  practices  vary  significantly  by State.  Despite barriers  identified,  both child 

support and vital  records  agencies  support the paternity  establishment  effort  and report 

largely  effective  interaction  with each other.  Child  support and vital  records  agencies  also 

rate birthing  hospitals  largely  capable  and willing  to assist in the voluntary 

acknowledgment  process.  However,  a number  of agency  respondents  report  confusion 

over their  respective  roles  in administering  the programs.  As acknowledgment  programs 

mature,  each States growth  and success will  rely  on interagency  collaboration. 

Program  implementation 
All States offer  voluntary  acknowledgment  services,  and 36 State child  support agencies 
report  Statewide birthing  hospital  implementation. 
Child  support  and vital records  agencies  agree  in-hospital  programs  encourage  voluntary 
acknowledgment  and report  acknowledgments  have risen  since program  implementation, 
Both State agencies  view in-hospital  programs  as helpful  to unmarried  parents  and report 
few parent  rescissions  of voluntary  acknowledgments. 
i  State Child Support and  Vital Records  Agency Practices  and Procedures 
States have made progress  in handling  paternity  documentation,  but both child  support  and 
vital  records  agencies  report  a continued  need for improvement  in the methods,  timeliness 
and completeness  of documentation  procedures. 
Acknowledgments  usually  go through  vital  records  systems before  reaching  child  support 
and are transferred  more  often by paper than electronically,  although  many  child  support 
agencies  desire  on-line  access to birth  registration  databases managed  by vital  records. 
Both child  support  and vital  records  agencies  give mixed responses  on the effect  of 
notarization  requirements,  but most report  it has a positive  impact or no impact on 
program  operations. 
Interaction  between  Child Support and  Vital Records  Agencies 
A majority  of both child  support and vital  records  agencies  report  effective  relationships 
with each other,  despite identifying  a number  of barriers  to collaboration. 
Both child  support  and vital  records  agencies  appear  somewhat unclear  about their  relative 
responsibilities  in administering  voluntary  acknowledgment  programs. 
A majority  of State child  support offices  which pay their  vital records  agencies  for tasks 
related  to paternity  acknowledgment,  report  payment  improves  services  or relationships, 
but some question  the appropriateness  of such payment. 
Contact with Birthing  Hospitals 
Most States have contacted  all of their hospitals  about paternity  services,  but only  half 
monitor  hospital  participation  by collecting  data on births  and acknowledgments. 
State child  support and vital records  agencies  report  hospital  staff are capable  and willing 
to administer  acknowledgments,  but they perceive  low staffing  as a problem  and are 
unclear  about the role of hospital  staff in communicating  with unmarried  parents. 
Most child  support agencies  which pay birthing  hospitals  for completed  voluntary 
acknowledgments  believe  the payment  helps the acknowledgment  process. 
Contact with Unmarried Parents 
Child  support agencies  report  that putative  fathers  more often create  a barrier  to 
acknowledging  than mothers,  and consider  the parent  relationship  to be the most important 
factor  in choosing  to acknowledge. 
Nearly  all child  support agencies  attempt to educate unmarried  parents  regarding  paternity 
acknowledgment,  and a few States follow-up  with parents  after hospital  discharge. 
ii  RECOMMENDATIONS 
Overall,  we find child  support and vital  records  agencies  are making  positive  changes  in 
the implementation  of hospital-based  paternity  acknowledgment  programs.  Both State 
agencies  are supportive  of the paternity  acknowledgment  effort,  have made efforts  to 
improve  their  documentation  procedures,  and are usually  able to communicate  effectively 
with each other.  Still,  considerable  improvement  could be made in forging  interagency 
partnerships.  Based on our findings,  we recommend  the Office of Child  Support 
Enforcement  (OCSE) take the following  actions  to improve  the State operation  of in-
hospital  voluntary  paternity  acknowledgment  programs.  The first and second 
recommendations  duplicate  those found  in a companion  report  on facility  participation 
subtitled  Hospital  Experiences  in Sample  States: 
AGENCY  INTERACTION  AND DZWSZON OF DUTIES.  Promote interagency 
collaboration,  and assure child support and vital records agencies more clearly define 
their respective  roles.  OCSE should provide  technical  assistance  to enhance  agency 
interaction  and encourage  joint  problem-solving  among child  support and vital records 
agencies  and should consider  encouraging  States to draft a flexible  interagency  agreement 
which  would make clear  the procedures  and activities  specific  to each agency. 
STATEWDE  HOSPITAL  ZMPLEMENTATZON AND ASSESSMENT.  Monitor  Statewide 
hospital implementation  by assuring all States collect  acknowledgment  data for each 
birthing  hospital  and by encouraging  development  of hospital assessment  procedures. 
OCSE should provide  technical  assistance  to States in creating  hospital  assessment 
procedures,  and should consider  developing  a uniform  reporting  mechanism  for States to 
monitor  nonmarital  birth  and acknowledgment  data per hospital  and to report  hospital 
assessment  procedures  and outcomes. 
USE OF FUNDS.  Clarify the appropriate  use by child support agencies  of Federal 
Financial  Participation  monies in compensating  vital records  agencies.  OCSE should 
provide  guidance  to State child  support agencies  in determining  the proper  use of Federal 
funds regarding  payment  to vital  records  agencies  for services  related  to voluntary 
paternity  acknowledgment  programs. 
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.  The Office  of the 

Assistant  Secretary  for Planning  and Evaluation  provided  its general  concurrence  with 

both this report  and the hospital  experiences  report. 

.. . 
111  TABLE  OF  CONTENTS 

PAGE 

EXECUTIVESUMMARY  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  i 

INTRODUCTION  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..l 

FINDINGS 

 Program  Implementation  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 

 Practices  and Procedures  ............................  .......  6 

 Interaction  Between Child  Support and Vital Records  Agencies  .....  ......  11 

 Contact  with Birthing  Hospitals  ........................  ......  18 

 Contact  with Parents  ...............................  ......  21 

RECOMMENDATIONS  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  24 

ENDNOTES  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  26 

APPENDICES 
A:  Sample Paternity  Acknowledgment  Forms  . . . . . . . . . . . . . . . . . . . . . . . .  A-l 
A-2  Paternity  acknowledgment  affidavit 

A-3  Three-way  paternity  acknowledgment  affidavit 

A-4  Mothers  Rejection  of Paternity  Affidavit 
 INTRODUCTION 

PURPOSE 
This  report  describes  State implementation  of in-hospital  voluntary  paternity 
acknowledgment  programs. 
BACKGROUND 
The Omnibus Budget Reconciliation  Act of  1993 (OBRA) amends 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.  Without  an establishment 
of paternity,  unmarried  mothers  may never  obtain  a child  support order  and gain access to 
the enforcement  services  of their  State child  support office.  Once a child  support order  is 
issued,  never-married  women  are as likely  to receive  payment  as are divorced  women. 
Many  States implemented  hospital-based  programs  before  this legislation,  and even now 
under the mandates,  the voluntary  paternity  acknowledgment  process  may be structured 
and administered  largely  at State discretion.  The voluntary  paternity  acknowledgment 
process  seeks to reduce  administrative  burdens  and provide  a healthier,  more positive 
introduction  to parenting  responsibilities.  In most States, birthing  hospitals  are the 
centerpiece  of this effort.  Under  OBRA,  State child  support agencies  must:  1) implement 
hospital-based  voluntary  paternity  acknowledgment  programs  in every  public  and private 
birthing  hospital;  2) require  that a witness  or notary  public  participate  in the signing  of 
voluntary  acknowledgments;  3) make available  voluntary  acknowledgment  outreach 
materials,  including  information  on parental  rights  and responsibilities,  and materials  for 
training  hospital  staff; 4) provide  Federal  Financial  Participation  (FFP) payments,  not to 
exceed 20 dollars,  to birthing  hospitals  for each voluntary  paternity  acknowledgment  at 
State discretion2;  and 5) monitor  birthing  hospital  compliance  on at least an annual 
basis.3 
The Personal  Responsibility  and Work  Opportunity  Reconciliation  Act of  1996 
(PRWORA)  further  defines  paternity  establishment  and encourages  State uniformity  and 
accountability.  PRWORA  makes the following  refinements  to the procedures  listed 
above:  1) provision  to mothers  and fathers  of both written  materials  and oral explanations 
regarding  the rights and responsibilities  of paternity  establishment;  2) a uniform  60-day 
window  for rescission  following  a voluntary  paternity  acknowledgment,  after which 
acknowledgment  would establish  a legal finding  of paternity;  and 3) inclusion  of State 
1  vital  records  agencies  in processing  paternity  acknowledgments  and child  support orders. 
Neither  OBRA nor PRWORA  precludes  the use of the birth  certificate  rather  than a 
separate paternity  acknowledgment  form  if the birth  certificate  includes  the necessary  data 
elements. 
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,  State child  support and vital  records  agencies  are in the 
process  of forging  new or enhanced  working  relationships.  This report  describes  those 
relationships  and the actions  taken by each to administer  their  States in-hospital  paternity 
acknowledgment  program.  Two companion  reports  will be issued as part of this study. 
The first entitled,  In-Hospital  Voluntary  Paternity  Acknowledgment  Programs:  Hospital 
Experiences  in Sample States (OEI-06-95-00161)  describes  program  usage nationwide 
using  survey  responses  from birthing  hospitals  and State agencies  in 15 sample  States,  and 
the second entitled,  In-Hospital  Voluntary  Paternity  Acknowledgment  Programs:  Best 
Practices  in Education  and Outreach  (OEI-06-95-00162)  highlights  innovative  training  of 
parents  and staff.  In addition,  two documents  were produced  for OCSE during  our 
inspection  entitled  Sample State Summaries  and  Common  Data Elements  - State 
Paternity  Acknowledgment  Forms  to meet immediate  needs pertaining  to implementation 
of PRWORA. 
METHODOLOGY 
After preinspection  research,  we used comprehensive  mail  surveys  to reach  State child 
support  and vital records  agencies.  In addition  to completing  the survey,  agencies  sent 
examples  of paternity  acknowledgment  outreach  materials  and photocopies  of their birth 
certificates  and voluntary  paternity  acknowledgment  forms.  For child  support  agencies, 
the pretested  survey  instrument  focused  on the procedures  in place for facilitating  hospital-
based paternity  acknowledgment  programs,  their contact  with and methods  of monitoring 
birthing  hospitals  and their  procedures  for acquiring  completed  voluntary  acknowledgment 
forms. 
For vital  records  agencies,  our focus was on the path of paternity  documentation  and 
collection  of acknowledgment  data,  but also covered  interaction  with child  support offices, 
outreach  to birthing  hospitals  and applicable  State laws governing  the use of birth  registry 
information.  Vital records  surveys  were sent to the chief  registrar  in each State, the 
District  of Colombia  and the City  of New York.  In nearly  all cases,  the registrars 
themselves  completed  the survey.  Child  support enforcement  agency  surveys  were sent to 
the central  child  support  (IV-D) office  in every  State and the District  of Columbia,  where 
respondents  were typically  child  support directors  or paternity  program  coordinators.4  In 
some cases,  small groups  of agency  officers  completed  the form  together.  We received 
completed  surveys  and documents  from every  State child  support and vital  records  agency 
surveyed. 5 
This  study was conducted  in accordance  with the Quality  Standards  for Inspections  issued 
by the Presidents  Council  on Integrity  and Efficiency. 
2  FINDINGS 

All States have established  in-hospital  programs  for voluntary  paternity  acknowledgment, 
although  practices  and experiences  vary  significantly  by State.  Despite  a number  of 
barriers  identified,  both child  support and vital  records  agencies  support the paternity 
establishment  effort  and report  largely  effective  interaction  with each other.  Even though 
many  States are still early  in implementation,  much progress  has been made toward better 
interagency  cooperation  and smoother  paternity  documentation  procedures. 
However,  considerable  improvement  could  still be made in forging  interagency 
partnerships.  A number  of vital  records  and child  support  agencies  report  confusion  over 
their  respective  roles  in administering  the in-hospital  programs.  They  also sometimes 
struggle  in reconciling  the long-established  vital  records  process  of birth  registration  with 
the child  support objective  of establishing  paternity  for issuing child  support orders. 
Although  many  State agencies  have created  successful  working  relationships  in the last 
several  years,  others  have made little effort  to work together,  particularly  regarding  the 
transfer  of paternity  documentation.  As in-hospital  acknowledgment  programs  mature, 
each States growth  and success will rely  on interagency  teamwork. 
Both State agencies  report  birthing  hospitals  largely  capable  and willing  to assist in the 
voluntary  acknowledgment  process.  Most child  support  and vital  records  respondents 
view their  relationships  with hospitals  as effective  (with vital  records  reporting  stronger 
ties),  but only  half of child  support  agencies  monitor  hospital  participation  by collecting 
data on nonmarital  births  and acknowledgments  received  per hospital.  Additionally,  the:x-e 
is disagreement  regarding  the appropriate  role of hospital  staff in assisting  unmarried 
parents,  and wide State variation  in the use of outreach  and educational  materials  for 
mothers  and putative  fathers. 
PROGRAM  IMPLEMENTATION 
All States Offer  Voluntary Acknowledgment  Services,  Although  Not Every Program  is 
Yet Statewide,  and Both  Child Support and  Vital Records  Agencies  Give a Positive 
Evaluation  of  Program  Impact. 
Most States offered  some tvne of voluntary  acknowledgment  service  nrior  to the Federal 
mandate,  but these nractices  did not meet current  nrogram  obiectives. 
Forty-three  vital records  agencies  and 39 child  support agencies  report  they used a method 
of voluntary  acknowledgment  prior  to the Federal  mandates,  and a few States started 
procedures  as early  as the  1940s and 50s.  But these programs  usually  lacked widespread 
hospital  involvement6 and linkage  to the birth  registration  process.  Implementation  for 
these early  programs  typically  included  only  the availability  of acknowledgment  forms 
without  much hospital  responsibility  to promote  the program  or to explain  paternity 
establishment  to parents. 
3 
 A number  of States took the opportunity  of new Federal  policy  to make other  changes  in 

their  acknowledgment  procedures  that were not mentioned  in OBRA.  For example,  some 

States began requiring  notarization  of paternity  affidavits,  changed  the level  of 

presumption  given to a voluntary  acknowledgment,  or added previously  missing 

acknowledgment  revocation  procedures.  A typical  State response  was  (before the law) 

we added the name of the father  to the birth cert@cate when he signed an 

acknowledgment,  but the form  had no real legal significance,  VaInd  we used paternity 

a$+idavits,but we didnt  collect data or keep track of their use per  hospital.   Many 

mentioned  they  only kept forms  at the public  health ofSice and didnt promote  the idea  (of 

paternity  acknowledgment).   PRWORA  requires  the U.S.  Department  of Health  and 

Human  Services  to list a standard  set of data elements  to serve as a model  for States in 

creating  paternity  acknowledgment  forms  or modifying  their  birth  certificates,  with the 

intent  that common  data elements  may facilitate  interagency  and interstate  sharing  of 

information.  Although  all States have created  affidavits  for paternity  acknowledgment,  a 

few use these forms  only  when acknowledgment  occurs  out of the hospital,  relying  on the 

signing  of the birth  certificate  for in-hospital  acknowledgment  (See Appendix  A-2 for an 

example  of a paternity  acknowledgment  affidavit. 

Most Child  Sunnort  Agencies  Have Contacted  All of Their  States Birthing  Hosnitals 

Regarding  Paternitv  Services,  and 36 Report  Statewide  Program  Imnlementation. 

Thirty-six  child  support  agencies  (77 percent)  report  all birthing  hospitals  are participating 

in their  paternity  acknowledgment  program.  An additional  three  States have contacted  all 

birthing  hospitals  in their  State to inform  them of the program  and to assist in offering 

paternity  acknowledgment  services  to parents,  but do not yet report  Statewide 

implementation.  The remaining  12 child  support agencies  have  not yet contacted  all 

birthing  hospitals  in their  State.  In States without  complete  birthing  hospital  participation, 

the following  reasons  are given  for the delay:  1) too early  for their  office  to require 

hospitals  to participate  (five States);  2) too early  for their  child  support  staff to have 

contacted  every  State birthing  hospital  (three  States); and 3) agency  first targeted  birthing 

hospitals  with a higher  incidence  of nonmarital  births  before  attempting  Statewide 

implementation  (two States).  A total  of eight  States,  including  some which  report  full 

implementation  and some which  have not yet gone Statewide,  report  they have targeted 

high-risk  hospitals  for special  attention. 

Child  support  and vital  records  agencies  agree in-hospital  nrograms  encourage  voluntary 

patemitv  acknowledgment,  and a majoritv  of States renort  acknowledgments  have risen 

since implementation  of the Federal  provisions. 

Forty-four  of the responding  child  support offices  (90 percent)  deem the in-hospital 

process  very helpful  or helpful  in encouraging  unmarried  parents  to voluntarily 

acknowledge  paternity.  Vital  records  offices  share this view,  but not as strongly,  with 33 

(66 percent)  reporting  hospital-based  programs  are helpful  or very helpful  in encouraging 

acknowledgments,  and an additional  eight  (16 percent)  rating  the programs  as somewhat 

helpful.  Thirty-six  child  support agencies  (72 percent)  and 27 vital  records  agencies  (59 

percent)  report  a higher  or much higher  number  of acknowledgments  have been received 
 since  implementing  OBRA.  Most other  respondents  from both  State agencies  report  no 
change  due to the Federal  mandates,  or that it is too early  in implementation  to evaluate. 
Only  one vital  records  agency  claims  acknowledgments  are actually  somewhat  lower  since 
implementation. 
Child  support  agencies  renort  few rescissions  of in-hospital  natemitv  acknowledgments. 
Nearly  90 percent  of the 28 State child  support agencies  which  allow  revocation  of a 
voluntary  paternity  acknowledgment  (usually  within  30 to 90 days) report  few or no 
rescissions  of acknowledgments  since program  implementation.  The low incidence  of 
rescission  appears to be a strong  endorsement  of voluntary  acknowledgment,  but using the 
number  of rescissions  as a performance  measure  for States is limited  somewhat by the 
absence  of a baseline:  three-fourths  of States did not keep records  of rescissions  before 
OBRA.  Implementation  of PRWORA  will require  States to adopt a 60-day rescission 
period,  and does not specify  whether  revocation  procedures  should be administrative  or 
judicial. 
Child Support and  Vital Records  Agencies  Perceive  In-Hospital  Programs  as Helpful  to 
Parents  and Find Advantages  to At-Birth Acknowledgment  Far  Outweigh Disadvantages. 
Child  support  and vital  records  agencies  believe  in-hospital  programs  are helpful  or very 
helpful  to parents  (47 child  support  and 42 vital  records  agencies).  When asked to select 
specific  advantages  in-hospital  programs  provide  to parents,  37 respondents  (73 percent) 
selected  five  or more.  The most common  advantages  identified  are the father  is more 
receptive  at birth,  the father  is more  likely  to be present  at birth,  and parents  are 
guaranteed  exposure  to their parental  rights  and responsibilities  (see Table  1). 
Table 1:  ADVANTAGES  FOR PARENTS IN ACKNOWLEDGING 
PATERNITY AT THE HOSPITAL 
Child Support  Vital Records 
Father More Receptive  to Acknowledging  at Birth 
 96%  76% 
(48)  (35) 
Father More Likely to Be Present at Birth than Later 
 86%  76% 
(43)  (35) 
Parents Receive  Exposure  to Rights and Responsibilities 
 86%  48% 
(43)  (22) 
Paperwork  Easier Than After Hospital Dismissal 
 80%  74% 
(40)  (34) 
Parents Avoid Cost and Stress of Adjudication 
 78%  59% 
0%  (27) 
Parents Avoid Fee for Amending the Birth Certificate 
 68%  53% 
(34)  (24) 
5 
 The sharpest  contrast  between  child  support and vital  records  agencies  in reporting 
advantages  was the exposure  of parents  to their  rights  and responsibilities.  Forty-three 
child  support  respondents  see this as an advantage,  compared  with only  22 vital  records 
agencies.  This may be caused  in part by some vital  records  agencies  not recognizing 
exposure  about rights  and responsibilities  as an objective  of the in-hospital  program  (see 
Table  8 for further  explanation  of the role of hospital  staff). 
State child  support  and vital  records  agencies  find far fewer disadvantages  with  in-hospital 
acknowledgments  (see Table 2).  Twenty-two  respondents  selected  only  one disadvantage, 
and only  one listed four or more disadvantages.  Both child  support and vital records 
agencies  perceive  the biggest disadvantage  to be that parents  may acknowledge  without  a 
true understanding  of what they  are signing.  Vital records  respondents  unanimously  view 
discouragement  of mothers  to seek prenatal  care as a disadvantage,  but child  support 
agencies  select this only  rarely.  We find no ready  explanation  for this discrepancy,  but 
note that most vital records  offices  are housed within  States public  health  departments 
and,  therefore,  State registrars  may be closer  to the issue of prenatal  care. 
Table 2:  DISADVANTAGES  FOR PARENTS IN ACKNOWLEDGING 
PATERNITY AT THE HOSPITAL 
Child  Vital 
SUPpofi  Records 
May Acknowledge  Without a True  Understanding  of Its Implications 
 61%  78% 
(22)  (25) 
May Discourage  Some Fathers from Visiting the Hospital 
 31%  13% 
(11)  (4) 
May Lead to More Rescissions 
 14%  25% 
(3  (8) 
May Jeopardize  Moms Custodial Rights 
 14%  9% 
(5)  (3) 
May Discourage  Mothers  from Prenatal Care 
 6%  100% 
(2)  (45) 
PRACTICES  AND PROCEDURES 
States are  Fairly  Uniform  in the Routine Administration  of Acknowledgments. 
Legislation  in 47 States already  requires  the father  to sign an acknowledgment  of paternity 
before  his name may be added to the birth  certificate,  a provision  found in PRWORA.  In 
22 States,  parents  may acknowledge  paternity  before  a child  is born  and 27 States have 
provisions  allowing  the father  to sign an acknowledgment  even  if the mother  is married  to 
someone  else.  The most common  method  for accomplishing  this is a three-way  paternity 
affidavit  which  requires  the signatures  of the father,  mother  and husband  (see Appendix 
A-3). 
6 
 For parents  who wait until  after their  hospital  stay to acknowledge  paternity,  most States 
(47) allow the birth  certificate  to be amended  to add the name of the father  after the birth 
has been registered.  Thirty-four  of these States (71 percent)  charge  a fee for post-
registration  amendment,  ranging  from  two to twenty-six  dollars,  with a median  payment 
of ten dollars.7  When  asked whether  they think  this fee discourages  parents  from putting 
the fathers  name on the birth  certificate,  vital  records  agencies  in only  three  States view 
the fee as a problem.  A few of the States which  charge  are willing  to waive fees if 
requested  by the parents  or by the child  support  agency. 
States have  Made  Progress  in Transfer-kg  Paternity Information  from  Hospitals  to 
Child Support Agencies,  But Report  a Continued  Need for  Improvement  in the Methods, 
Timeliness  and  Completeness  of Documentation  Procedures. 
Acknowledgments  typically  go throuph  vital  records  systems before  reachin?  child  support 
agencies,  and are transferred  more often bv paper  than electronically. 
Paternity  information  must get from  the birthing  h  ital to the child  support agency  for a 
support order  to be established.  As discussed  earl  acknowledgments  may be completed 
on separate  affidavit  forms  or may be included  on  e birth  certificate  itself.  The path of 
documenting  acknowledgments  varies  by Sta  ally goes from birthing  hospitals  to 
the vital  records  agency,  and then to the child  su  rt office.  Acknowledgment 
information  is received  by child  support offices  one or more  of the following  basic 
methods:  1) 23 State vital  records  systems  wledgments  from birthing 
hospitals  and send photocopies  of these to child  s  ort,  either  automatically  or by request 
(43 percent);  2) 18 States use a multi-copy  ca  ss paternity  affidavit  form,  with one 
copy typically  going to the mother,  one to the  , one to vital  records  and a fourth  to 
child  support enforcement,  allowing  both vital  re  s and child  support to receive 
acknowledgments  directly  from the hospital  (34  nt);  3) 15 State vital  records 
systems provide  child  support personnel  with  access to paternity  and birth 
registration  information  (28 percent);  4) five  ital records  systems create  an 
electronic  or paper  list of available  acknowledgm  s from  which child  support may 
request copies  (nine percent);  and 5) in two  1s send photocopies  of 
acknowledgments  to child  support and original  dot  ents to vital  records  (four 
percent) .9*10 
Child  Support  agencies  desire  on-line  access to natemity  or birth  registration  databases 
managed  by vital  records. 

Although  44 vital records  agencies 

Certificate  (EBC) systems for registration  of 
 the remaining  vital  records 
agencies  all report  plans to go paperless,  
 of child  support offices  still 
receive  only  paper documentation  of paternity 
 from  vital  records. l1  As 
stated above,  child  support respondents  in 13 State 
 (28 percent)  are able to access 
information  on-line.  One method  of 
 records  agencies  to 
transfer  information  upon request  or 
 the primary  public  health  database to 
a smaller  database  shared by child  support offices. 
 support access to the 
7  I 
 portion  of the birth  registration  information  directly  related  to paternity  acknowledgment. 

This method  of limited  access may be a result  of State privacy  statutes which prohibit 

access to and use of birth  registration  information  by child  support unless  a support case 

has been opened.  In these cases,  vital  records  grants  only  authorized  access to paternity 

information.  In Kansas,  for example,  the vital records  agency provides  child  support staff 

with electronic  access to a limited  number  of data elements  for all paternity 

acknowledgments  received,  regardless  of their  child  support  status.  When  caseworkers 

find acknowledgments  on-line  that are needed  for child  support cases,  they  request  a 

certified  copy  of the acknowledgment. 

Another  method  of establishing  on-line  capability  allows child  support to directly  access 

vital  records  birth  registration  database  on a read-only  basis.  This method  is typically 

faster than the method  mentioned  above,  which  requires  vital records  agencies  to transfer 

information  to a second  shared database.  One State which uses this method  reports  child 

support has on-line  access to birth  registrations,  including  Social  Security  numbers  of 

parents,  just  one day after the data arrives  in the State vital  records  office.  An alternative 

to on-line  access requires  vital records  agencies  to create  an index for child  support  from 

its birth  registration  database,  allowing  child  support caseworkers  the electronic  use and 

storage  of information.  The index may or may not include  all available  data elements. 

For example,  the vital  records  office  in California  optically  scans acknowledgments  into a 

database  where key data fields  are entered  to create  an index.  The index information  is 

then provided  electronically  to child  support offices  on diskette. 

Twenty  child  support  agencies  report  that providing  on-line  access to paternity  databases  is 

the most important  change  vital records  agencies  could make to their  end of the voluntary 

acknowledgment  process.  As both vital  records  and child  support agencies  begin to rely 

more  on automation,  on-line  systems,  once in place,  may  increase  efficiency  in 

transferring  information.  At this stage in program  implementation,  however,  those who 

receive  information  electronically  did not report  faster  service  than those with paper 

transmission.  Due to this marginal  outcome  and to the uniqueness  of some States 

procedures,  it shouldnt  be assumed that electronic  transfer  is always  preferable.  A 

number  of child  support  agencies,  particularly  in States which have few local  or regional 

agency  offices,  report  they  are satisfied  with paper  transfer  and may not wish to expend 

the cost and man-hours  required  to make such electronic  transfer  systems  operational. 

Timeliness  in receiving  acknowledgments  is a problem  for some child  sunport  agencies. 

Nine child  support agencies  (21 percent)  are concerned  about timeliness  in receiving 

paternity  information,  and six of these offices  report  waits of three  months  or more  for 

paper  or electronic  transfer.  Of the other responding  States, 28 report  no problem  in 

receiving  documentation;  three  consider  their program  too new to evaluate;  four report 

lateness as only  an occasional  problem,  and two didnt know  if timeliness  was a 

problem. ** Some of those who were not concerned  about timeliness  had to wait just  as 

long for acknowledgment  information  as those who were concerned,  but said that the wait 

was not a problem.  One child  support respondent  wrote that this time  can be used  for) 

preparing  other aspects of the case.  But delays  in receiving  acknowledgment 

8  information  may cause unnecessary  scheduling  of paternity  interviews  and prevent  the 
child  support  agency  from  accurately  reporting  acknowledgments  received. 
If the wait for acknowledgments  is excessive,  it is usually  the transfer  from  vital  records 
to child  support that presents  a problem.  Birthing  hospitals  are never  cited as a cause of 
excessive  wait:  forty-two  State vital  records  systems  (at the State, regional  or local  level) 
receive  acknowledgment  information  from  birthing  hospitals  within  two weeks,  with a 
median  time of  10 days.  Hospitals  are just  as timely  in providing  information  to child 
support offices  in States where  acknowledgments  are sent by hospitals  to both  State 
agencies  simultaneously.  For example,  Virginia  hospitals  send copies  of acknowledgments 
in batches  to child  support the fifth working  day of each month.  Among  States which 
require  information  to go through  vital records  to child  support,  however,  there  is large 
variance  in the amount  of time child  support must wait for information.  Reports  of 
average  transmission  time vary  from one day to six months,  with most occurring  around 
thirty  days. 
Information  is sent by vital  records  to child  support either  upon request,  in batches,  or as-
received.  We found no real differences  in timeliness  between  these methods.  The key to 
reducing  problems  appears  to be in jointly  establishing  a firm  schedule  that is reasonable 
to both agencies  and that suits the circumstances  and needs of the individual  State.  In 
Kentucky,  an administrative  assistant  from the child  support office  simply  goes to the 
State vital records  office  in person  each week to collect  paternity  acknowledgment 
information.  No matter  which method  is used,  acknowledgments  in a given  State could 
actually  travel  through  four agency  offices:  hospitals  could  send all birth  registration 
information  to the local  registrar  or town clerk  (l),  who may check the forms  for 
completeness  and send them on to the State vital  records  office  (2), who upon  formally 
registering  the births  sends information  to the State child  support office  (3), through  which 
the acknowledgment  is sent to local child  support enforcement  caseworkers  (4).  However, 
we find no connection  between  delays  and the number  of offices  involved. 
Child  support  agencies  want more birth  information  for establishing  child  support  orders. 
Twenty-two  child  support  respondents  report  they  would  like more birth  registration 
information  than they currently  receive,  typically  for locating  the noncustodial  parent  after 
a child  support order  has been issued or for matching  child  support cases to paternity 
acknowledgments.  In States which do not use a separate  form  for in-hospital 
acknowledgments,  child  support agencies  are likely  to receive  only  the portion  of the birth 
certificate  which  includes  the childs  name and parents  names,  dates of birth,  signatures, 
and possibly  Social  Security  numbers.  Birth certificates  are likely  to contain  much more 
information  and,  depending  upon their  obligation  to privacy  statutes mentioned  above, 
vital records  agencies  might be able to provide  child  support with a greater  number  of 
data elements.  In States which use a separate  paternity  affidavit  for all acknowledgments, 
additional  data elements  may need to be added to the form.  When  asked what additional 
information  they would  like to receive,  child  support  agencies  most frequently  cite Social 
Security  numbers  and the fathers  and mothers  addresses  and employers. 
9 
 Case-Matching  is Performed  by Half  of States,  Using Names  of the Parents  and  Child. 
Just over half  of State child  support enforcement  agencies  report  using case-matching 
procedures  which  allow them to match new paternity  acknowledgments  against existing 
child  support cases.  Of the 26 States which match,  20 rely  on the central  State child 
support office  for matching,  three  on the local or regional  child  support offices,  two on 
vital  records  offices  and one State uses a private  contractor.  These case matches  are most 
often completed  by States continually  as acknowledgments  come in, but a number  of 
States match new acknowledgments  to cases in batches  on a monthly  or weekly  basis.  A 
few perform  daily  case-matches  which  include  both new and existing  acknowledgments. 
Information  matched  most often  includes  mothers  name (24 States), fathers  name (23 
States) and childs  name  (22 States).  Other matching  information  includes  childs  date of 
birth,  mothers  and fathers  Social  Security  Numbers,  and mothers  date of birth. 
Both  Child Support and  Vital Records  Agencies  Give Mixed Responses  on the Effect  of 
Notarization  Requirements,  But Most Report  it Has a Positive Impact  or No Impact  on 
Program  Operations. 
Forty-three  vital records  offices  report  their  State requires  notarization  of paternity 
acknowledgments,  and the remainder  require  a witness.  Some minor  policy  variations 
exist,  such as the State which  requires  notarization  only  for minor  parents,  and a few 
States which  notarize  only  when the acknowledgment  is signed outside of the hospital 
setting,  using a witness  for in-hospital  signings.  Varied  viewpoints  exist regarding 
notarization,  with some believing  it creates  an administrative  barrier  to acknowledgment 
and others  advocating  its formality.  A surprising  number  of agency  respondents  are 
neutral  on the subject.  Only  two vital records  offices  (5 percent)  in States which  require 
notarization  claim  the requirement  has a negative  impact  on voluntary  acknowledgment 
procedures,  while  17 States (41 percent)  report  a positive  impact and 22 States (54 
percent)  report  it has no impact on program  operations.  But of child  support  respondents 
in these same States, more  report  a negative  impact  (10 States or 28 percent),  while  nearly 
half  (49 percent)  believe  notarization  to have a positive  effect  and the remaining  8 States 
(23 percent)  report  no impact.  Of the seven child  support  agencies  in States not requiring 
notarization,  six opposed  the use of notaries. 
Proponents  of notarization  gave comments  such as  Notarization ensures that we know  the 
identity of the people  signing  and  Parents take the process  more seriously  if a notary is 
present and seem to appreciate  the formality  notarization  brings.   Opponents  of 
notarization  claim  that notaries  are often unavailable  during  unmarried  mothers  short 
hospital  stays and that it is too difficult  for rural  hospitals  to keep notaries  on staff.  One 
vital records  office  contributed  the following:  We did require notarization,  but it ofen 
disrupted the process.  An  investigation  into the reason notarization  was required revealed 
that the first  State to do acknowledgments  required it so everyone else followed!   
10 
 INTERACTION  BETWEEN  CHILD SUPPORT  AND VITAL RECORDS  AGENCIES 
In a Number  of States, Both  Child Support and  Vital Records  Agencies  Appear  Unclear 
About  Their  Own and Each  Others Responsibilities  in Administering  Acknowledgments. 
There  is evident  confusion  over the division  of responsibility  between  child  support  and vital 
records  agencies  in administering  acknowledgments.  When  asked which  agency  in their  State 
is primarily  responsible  for the voluntary  acknowledgment  process,  child  support  and vital 
records  agencies  in nineteen  States gave different  answers.  Of those which  gave 
contradictory  answers,  the responses  are as follows:  nine  States believe  they  alone  are 
responsible  when their  counterpart  reports  sharing  responsibility  equally,  seven  States each 
name themselves  as carrying  primary  responsibility,  two States believe  the other  agency  is 
alone  in responsibility  when that agency  claims  equal sharing  of responsibility,  and one State 
disagreed  as to whether  their  shared responsibility  lies at the State or the regional  level.  It 
appears that a number  of agencies  are unclear  about what the other  is doing,  and this could 
create delays  in documentation,  as well as gaps in service  to hospitals  and in outreach  to 
unmarried  parents. 
While Some  of  Child Support Agencies  Still Lack  n-es to Vital Records  Agencies,  Most 
Already  Report a Considerable  Degree  of  Cooperation. 
A varietv  of mechanisms  for enhancing  interagency  collaboration  are used. 
The level of collaboration  between  vital  records  and child  support agencies  varies  greatly  by 
State.  A few child  support agencies  have established  documentation  procedures  which 
largely  circumvent  their  States vital  records  agency.  For example,  one State possesses  a 
statute which  instructs  hospitals  to forward  completed  acknowledgments  to the State child 
support agency  which  serves as the sole repository  of the forms.  Vital records  is therefore 
not involved  with this States voluntary  acknowledgment  program  and receives  only  the birth 
certificates  for registration.  Nationwide,  however,  only  three  States report  their  child 
support agency  houses  their  States sole paternity  database. 
Most State child  support offices  hope to work together  with vital  records  to administer  the 
voluntary  acknowledgment  process,  and with the implementation  of PRWORA,  vital records 
agencies  will be required  to become  involved  in processing  acknowledgments.  By working 
together,  many  child  support  officials  hope to reap the benefit  of vital  records  long-standing 
relationship  with birthing  hospitals.  The most common  mechanisms  in facilitating  the 
acknowledgment  process  include  communication  between  key personnel  and informal 
communication  (see Table  3 for a complete  listing).13  Examples  of other types of 
interagency  cooperation  not mentioned  in the table include jointly  sponsoring  State 
legislation,  sharing  aggregate  data regarding  nonmarital  births,  and organizing  in-house  or 
contract  training  of local registrars  and county  child  support  staffers.  New Jersey,  among 
other States,  has coordinated  joint  training  sessions  for child  support and vital  records  staff. 
11 
 Table 3:  INTERAGENCY  MECHANISMS 
Child Support  Vital Records 
Communication  Between Key Personnel  86%  71% 
(44)  (36) 
Informal  Staff Communication  77%  75% 
(3%  (38) 
Shared Training  Efforts  for Hospital Staff  51%  51% 
(26)  (26) 
Interagency  Agreement  39%  47% 
(20)  (24) 
Shared Automated  Database  37%  35% 
(1%  (18) 
Joint Agency Committee  or Task Force  18%  16% 
(9)  (8) 
Shared Training  Efforts  for Parents  14%  12% 
(7)  (6) 
States which  employ  multinle  interagency  mechanisms  also report  more effective  child 
sunnort  and vital  records  agency  relationshins  and fewer barriers  to cooperation. 
Child  support  and vital  records  agencies  which use more than one interagency  mechanism 
listed in Table  3 are much more  likely  to rate their  relationships  as effective  or very 
effective.  In fact,  the effectiveness  rating  by both became  more positive  as the number  of 
interactive  tools  increased.  Of those with only  one mechanism  in place,  48 percent  rate their 
relationship  with their  counterpart  as effective  or very  effective,  compared  with 82 percent 
which use four  or more mechanisms.  Nearly  half of these also use more  interactive  training 
methods  (workshops,  on-site  visits).  Another  measure  of satisfaction  is the absence  of 
perceived  barriers  to interagency  cooperation.  As the number  of interagency  mechanisms 
used increases,  child  support and vital  records  agencies  are more  likely  to report  no barriers 
to collaboration:  25 percent  of those which use only  one mechanism  perceived  no barriers, 
whereas  43 percent  of those who use four or more mechanisms  perceived  no barriers. 
Therefore,  in States where  agencies  communicate  more  often,  there  are fewer perceived 
barriers  to program  operations. 
12 
 Some  Child Support Agencies  May Perform  Duties Alone  that Are Better-Suited  to 
Collaboration  with Vital Records  Agencies. 
Vital records  agencies  often already  have the infrastructure  needed to collect  and store 

paternity  information. 

State child  support offices  sometimes  create  structures  that may already  be in place.  One 

example  is the collection  of birth  registration  and paternity  acknowledgment  data.  State vital 

records  offices  are usually  better-equipped  to manage  large databases,  and in States where  the 

child  support  offices  capitalize  on this ability  there  are interagency  agreements  which  allow 

for the regular  transfer  of both  individual  and aggregate  data from  vital records  agencies  to 

child  support agencies.  In trying  to find data which may eventually  be used by Federal  and 

State child  support  officials  for performance  measures  of voluntary  acknowledgment 

programs,  we asked vital  records  offices  what data relating  to paternity  they already  collect. 

The most common  data elements  collected  by vital  records  are nonmarital  births  that 

occurred  in the State (38 States),  nonmarital  births  to State residents  (37 States), 

acknowledgments  received  from  all sources  (29 States),  acknowledgments  received  from 

hospitals  (26 States),  and acknowledgments  received  from each individual  hospital  (16 

States).  If child  support agencies  communicate  their  needs,  vital  records  offices  may be able 

to add other  desired  fields  to their  birth  registration  database. 

Both vital  records  and child  sunnort  agencies  offer  training  for hospital  staff. 

Another  area of possible  underutilization  of pre-existing  vital records  services  is the training 

of hospital  staff in the voluntary  acknowledgment  process.  Both child  support and vital 

records  agencies  currently  target  many  of the same hospital  staff and use similar  methods. 

All of the vital records  agencies  responding  report  they train  hospital  staff in the birth 

registration  process.  Forty-seven  States train  birth  registration  clerks,  18 States train 

obstetrics  nurses and  15 States train  additional  obstetrics  staff.  Other hospital  staff who may 

receive  training  from  vital records  include  medical  social  workers,  nursery  attendants  and 

pediatrics  staff.  However,  although  hospital  staff training  by vital  records  is nearly 

universal,  12 vital  records  agencies  (24 percent)  do not include  information  about the 

voluntary  paternity  acknowledgment  process  in their birthing  hospital  training. 

As for child  support  agencies,  46 of the 51 IV-D respondents  report  they train  hospital  staff 

in the voluntary  acknowledgment  process  as is mandated  by OBFU.  Forty-two  child  support 

offices  train  birth  registrars,  29 train  obstetrics  nurses and 24 train  other  obstetrics  staff. 

Other hospital  staff targeted  are medical  social workers,  nursery  attendants  and pediatrics 

staff.  The type of training  and degree  of effort  varies  widely,  with brochures  and on-site 

seminars  topping  the list (see Table 4). 

13 
 Table 4:  TYPE OF TRAINING PROVIDED TO BIRTHING HOSPITAL STAFF 
Child Support  Vital Records 
Brochures/Pamphlets  89%  54% 
(41)  (26) 
On-site Lectures  or Seminars  67%  71% 
(31)  (34) 
Other (examples:  regional workshops,  individual  65%  40% 
meetings,  l-800  numbers,  etc.)  (30)  (1% 
Training  Video  33%  21% 
(15)  (10) 
Although  it is unlikely  to replace  training  by child  support agency  staff,  adding paternity 
acknowledgment  materials  to vital  records  agencies  on-going,  systematic  training  may save 
child  support  agencies  time and resources  used to meet continuing  hospital  needs and enhance 
hospital  participation.  Depending  upon  State-specific  factors  such as respective  size of 
agency  staff and number  of birthing  hospitals  served,  it may be appropriate  for child  support 
to prepare  training  materials  which  address the paternity  acknowledgment  process  and 
encourage  vital  records  to help  in distributing  the information.  Vital  records  offices  have 
long communicated  with hospital  personnel  on the birth  registration  process  and,  as reported 
above,  they usually  enjoy  positive  relationships  with hospital  birth  registration  staff.  Even if 
child  support  staff prefer  to conduct  training  efforts  on paternity  themselves,  they may still 
benefit  from  some combination  of effort  with vital  records  in holding joint  hospital  training 
seminars,  distributing  forms or brochures,  creating  new instructional  materials  and 
conducting  follow-up  contact  with hospital  birth  registration  personnel. 
Regardless  of the training  methods  used,  child  support and vital  records  agency  follow-up  to 
initial  hospital  training  efforts  is lacking.  Most child  support agencies  (39 States) rely 
primarily  on hospitals  notifying  them when  in need of additional  instruction  and materials  for 
new hospital  employees.  More proactive  methods  by child  support to provide  additional 
instruction  are less common:  18 child  support agencies  conduct  periodic  phone  checks  and 
16 conduct  status checks  in person.  Only  six State child  support agencies  automatically  send 
new materials  throughout  the year.  Hospital  staff training  materials  are most often created 
by child  support offices  (44 States),  with some materials  created  by vital records  staff (16 
States), private  contractors  (11 States),  local child  support offices  (seven States),  and OCSE 
(two percent). 
14 
 A Majority of  Both  Child Support and  Vital Records  Agencies  Characterize  Their 
Relationship  with the  Other Agency as Effective  or  Very Effective,  Despite  Identifying  a 
Number  of Barriers  to Collaboration. 
When asked to judge  their  relationship  with the State child  support enforcement  agency, 
31 vital records  offices  (62 percent)  report  the relationship  is effective  or very effective. 
Another  13 vital  records  offices  (26 percent)  say that their  relationship  is somewhat  effective 
and only  6 States (12 percent)  claim  an ineffective  relationship.  The ineffective  relationships 
are reported  to be largely  due to the perception  that their  child  support  agency  is trying  to 
reinvent the wheel  and establish  birth  registration  policy  and procedures  without  first 
consulting  them.  Typical  comments  included:  Child support ignores vital records 
programs  until they start to implement and then they initiate discussions,  and  The mission 
and priorities  of one agency are not necessarily  those of the other.   Some believe  vital 
records  agencies  would more readily  become  involved  if paternity  acknowledgments  were not 
viewed as solely  benefiting  child  support.  A number  of respondents  from both child  support 
and vital  records  agencies  echo this opinion  that paternity  acknowledgment  be viewed  from a 
broader  public  health  perspective.  One agency  representative  reports  the following:  One of 
the major impacts of this policy  is the d#iculty  in projecting  the image that paternity 
establishment  is for  all children born to unmarried parents  and not only for  child support 
clients.  
Of child  support  agencies,  36 respondents  (74 percent) judge  their relationship  with vital 
records  to be effective  or very effective.  Another  11 (22 percent)  assess their  relationship  as 
somewhat effective  and only  two child  support  offices  claim  an ineffective  relationship  with 
their  vital records  counterpart.  When child  support  respondents  offer  any negative  comments 
about vital  records,  they typically  mention  issues such as a slow pace of automation  and 
excessive  fastidiousness  regarding  form completion.  As shown in Table 5, child  support and 
vital records  agencies  differ  greatly  in what they  see as the most significant  barriers  to a 
more effective  relationship.  Twenty-two  child  support agencies  (45 percent)  find the greatest 
barriers  to be differences  in automation,  compared  with only  6 vital  records  agencies  (12 
percent).  Vital  records  find little or no funding  from  child  support for their  services  to be 
the greatest  barrier,  with 26 States citing  this 54 percent),  as contrasted  with only  12 child 
support agencies  (25 percent)  mentioning  funding.  Of those listing  barriers,  42 percent  of 
vital records  and 54 percent  of child  support  agencies  list only  one,  indicating  a fairly 
positive  view of the potential  for interagency  collaboration. 
15 
 II 
Table 5:  BARRIERS TO INTERAGENCY  COOPERATION 
Child Support  Vital Records 
No Barriers  to Interagency  Cooperation  31%  27% 
(15)  (13) 
Differences  in Automation  45%  12% 
(22)  (6) 
Little or No Funds from Child Support  25%  54% 
Agency to Vital Records Agency  (12)  (26) 
Inflexibility  by One Or Both Agencies  25%  8% 
(12)  (4) 
Statutory  Conflict  16%  17% 
63)  (8) 
Unclear About Relative Agency Responsibilities  12%  25% 
(6)  (12) 
Poor Communication  10%  21% 
(5)  (10) 
Fifteen  child  support  agencies  (31 percent)  and  13 vital  records  agencies  (27 percent)  report 
no barriers  at all to interagency  cooperation.  Nearly  all child  support and vital  records 
agencies  (96 percent),  indicating  no barriers  to cooperation,  also report  their  relationship 
with the other  agency  as effective  or very  effective  and that they have a high  level of 
interagency  communication:  all of the child  support agencies  reporting  no barriers  to 
interagency  cooperation  use informal  communication  and 87 percent  of them use 
communication  between  key personnel. 
Both  State Agencies  Express  Support for  Payments  by Child Support to  Vital Records. 
Vital records  agencies  strongly  desire child  sunnort payment  for their  services. 
The issue of payment  by child  support  agencies  for vital  records  services  is the most 
prominent  of the barriers  listed by vital  records  agencies  in Table 5, and most vital  records 
agencies believe  they  should be paid by child  support.  Twenty-two  vital  records  offices 
report  they are being  paid or have been paid  in some manner  by their child  support agency 
for services  connected  to voluntary  paternity  acknowledgment.  However,  fewer child 
support agencies  (19) report  they pay vital  records.  This discrepancy  may reflect  hesitancy 
on the part of a few child  support agencies  to claim  a payment  policy  because  they  are 
unsure  about the validity  of paying  vital records  under  Federal  guidelines. I4 Of child 
support offices  which  do not pay,  four claim  that payment  to vital records  is not allowed 
16 
 under  Federal  regulation.  At the same time,  17 of the  19 child  support  agencies  which do 
pay report  using Federal  funds. 
Of vital records  agencies  which  are paid,  81 percent  (17 States) report  the additional  funds 
are beneficial,  helping  their  offices  to process  voluntary  acknowledgments.  They report 
being paid most often for issuance  of certified  copies,  generation  of monthly  aggregate 
reports,  prorated  computer  use time and data entry  of paternity  forms.  Some others  are paid 
for on-line  access to paternity  databases  and a couple  are paid  in hours by assigning  a data 
entry  staff person  employed  by child  support to work  in vital  records.  Of the 30 vital 
records  agencies  which have never  been paid,  26 desire  payment.  When  asked why they 
believe  they  should be paid for paternity  acknowledgment  services,  15 report  they believe  it 
unfair  to expend resources  on a child  support objective  without compensation,  13 claim  they 
can provide  better  service  to child  support  if they  are paid,  and  10 report  they  simply  need 
more money  to process  acknowledgments.  As mentioned  before,  regulations  written  to 
interpret  OBRA require  that voluntary  acknowledgments  become  a part of the birth 
registration  process,  and PRWORA  mandates  involvement  of vital  records  in hospital-based 
programs.  Alluding  to this provision,  the Massachusetts  child  support office  writes about the 
importance  of compensating  vital  records  for involvement:  Ztmakes sense for  RVRS  (vital 
records) to be central repository  of all acknowledgments,  given their traditional function  of 
maintaining  records and this would provide  at least one link between  acknowledgments  and 
birth certificate  data matches and resulting reports.  (This incorporation  could) possibly 
require programming  changes on the part  of the vital records agency.  
Child  support  agencies  are divided  over  whether  to pay vital  records  for services  and 
products  related  to paternity.  but a maioritv  who do pay report  services  or relationships  have 
improved  as a result. 
Because child  support officials  may favor  paying  vital  records  but feel unable  to pay,  or 
conversely  may have made an agreement  to pay but no longer  favor  such payment,  we asked 
child  support respondents  about this important  issue in two ways.  First,  we asked if they 
favor paying  and why or why not.  Next,  we asked if they do pay or ever  have paid and 
what was the result.  Half of responding  child  support  agencies  say they believe  they  should 
pay vital  records  for products  and services  relating  to voluntary  paternity  acknowledgment, 
whether  they currently  pay or not. 
The most prominent  reasons  given by child  support  agencies  for paying  vital  records  agencies 
are simply that it seems unfair  not to compensate  vital  records  for work which  primarily 
benefits  child  support enforcement  (16 States),  that vital records  needs more money  to 
process  acknowledgments  (15 States),  and they  believe  they may receive  better  service  from 
vital  records  if they pay (14 States).  Of the remaining  half of child  support  agency 
respondents  who do not favor paying,  reasons  given  include  the belief  that it is the vital 
records  agencys job  to process  all birth  registration  documents  including  paternity 
acknowledgments  (20 States),  that the IV-D budget is already  too limited  (3 States),  that they 
send child  support  staffers to help process  acknowledgments  in the vital  statistics  offices  (3 
States),  and that they dont believe  the money  is truly  needed (2 States).  Of the  19 child 
support agencies  which  report  paying  vital  records  agencies,  17 pay currently  and two 
17  formerly  paid but no longer  do so.  When  asked if payment  improved  or enhanced  services, 
11 child  support agencies  who paid (69 percent)  said they did receive  better  service  and/or 
experienced  an improvement  in their  interagency  relationship  with vital records. 
CONTACT  WITH  BIRTHING  HOSPITALS 
Only Half  of State Child Support Agencies  Monitor  Hospital  Participation. 
Federal  law requires  under  OBRA that child  support agencies  annually  monitor  the 
participation  of every  birthing  hospital  in their  State.  At this point  in implementation,  only 
27 child  support offices  (53 percent)  monitor  hospital  participation.  Further,  in nearly  all of 
these States their  monitoring  consists  only  of collecting  data on the number  of 
acknowledgments  received  from the hospital  compared  with the number  of nonmarital  births 
the hospital  assisted.  This measure  requires  tracing  acknowledgments  to each specific 
hospital.  Fourteen  other  State child  support agencies  (27 percent)  track the number  of 
acknowledgments  that come from  each birthing  hospital,  but do not yet compare  these figures 
to the number  of nonmarital  births  assisted.  Only a few child  support agencies  have begun 
to truly  assess hospital  participation  by also evaluating  the process  the hospital  uses to 
complete  acknowledgments,  such as hospital  staff involvement  or parent use of outreach 
materials.  Further  description  of these assessment  efforts  are included  in a companion  report 
subtitled  Best Practices  in Education  and Outreach.  For child  support agencies  which pay 
hospitals  for processing  acknowledgments,  the financial  transaction  required  guarantees  a 
natural  count or tracking  of acknowledgments  per birthing  hospital. 
The Majority of State Child Support Agencies  Choose  Not to Pay Hospitals for  Completed 
Paternity Acknowledgments,  But Most Which Do Pay Believe  Payment Helps  Hospitals  and 
Enhances  their Acknowledgment  Program. 
Twenty  child  support agencies  (40 percent)  report  they either  do pay or had paid hospitals 
for acknowledgments  received.  The payment  amounts  range  between  10 and 25 dollars  per 
acknowledgment,  with  11 States paying  the median  of 20 dollars.  All but one State agency 
which  pays hospitals  reports  an improvement  in service  and in their  relationship  with 
hospitals  as a result of payment.  In States which  chose not to pay hospitals,  the main 
reasons  given by child  support agencies  include:  it is the hospitals job  to process  birth 
registration  information  and therefore  they  shouldnt  be compensated  (13 States); child 
support  funds are too limited  to pay (12 States),  and the amount  of money  is too small to 
matter to hospitals  (four States). 
Vital Records  Agencies  Report Somewhat  More Effective  Relationships  with Birthing 
Hospitals  than Do ChiM Support Agencies. 
Vital records  agencies  report  close ties with their  States birthing  hospitals.  Forty-four  vital 
records  offices  (90 percent  of those responding)  judge  their  relationship  with hospitals  as 
effective  or very effective.  Of child  support agencies,  36 (72 percent)  report  effective  or 
very  effective  working  relationships  with birthing  hospitals.  Of course,  hospital  birth 
registrars  are more  accustomed  to working  with vital  records  personnel,  having  long  standing 
18  relationships  due to the birth  registration  process.  Vital records  staff in a few States report 
they know the birth  registrars  by name in nearly  every  hospital  in their  State.  Child  support 
offices  which  have worked  closely  with their  vital  records  counterparts  appear to have the 
most positive  relationships  with birthing  hospitals.  In these cases,  hospitals  may benefit  from 
greater  interagency  collaboration  because their  State child  support and vital records  agencies 
have constructed  a unified  set of procedures  and send hospital  staff a clear,  repetitive  and 
singular  State message on the voluntary  acknowledgment  process. 
Both  Child Support and  Vital Records  Agencies  Perceive  Similar  Barriers  to Hospital 
Program  Participation,  the Greatest Being  Lack  of  Staff  to Administer Acknowledgments. 
Although  vital  records  agencies  may work well with hospitals  regarding  the birth  registration 
process,  we couldnt  assume that these collegial  relationships  extended  to the voluntary 
acknowledgment  process  specifically.  Therefore,  we asked vital  records  agencies  for any 
internal  facility  barriers  which  may hamper  hospital  participation  in acknowledgment 
programs.  The most common  barriers  to hospital  implementation  are shown in Table 6, but 
over 20 percent  of all agency  respondents  report  no internal  barriers  to hospital  participation. 
Child  support and vital  records  agencies  strongly  agree in identifying  lack of hospital  staff as 
the most significant  barrier  to hospital  participation. 
Table 6:  INTERNAL BARRIERS TO HOSPITAL PARTICIPATION 
Child Support  Vital Records 
No Barriers  Found 
 22%  20% 
(11)  (10) 
HospitaI Understaffed  to Deal with the Acknowledgment  Process 
 64%  63% 
(32)  (31) 
Staff Doesnt Recognize  the Importance  of Their  Role 
 46%  20% 
(23  (10) 
Staff is Inflexible  and Resistant to Change 
 20%  8% 
(10)  (4) 
Little or No Payment to Hospitals by Child Support Agency 
 16%  N/A 
(8) 
State Child Support and  Vital Records  Agencies  Report Hospital  Staff  are  Generally 
Positive and  Capable  of Administering  Acknowledgments,  But Appear  Unclear  Regarding 
the Appropriate  Role  of Hospital  Staff  in Communicating  with Unmamed  Parents. 
Few hospital  staff are viewed by child  support  and vital records  agencies  as reluctant  to 
participate  in voluntary  acknowledgment  programs. 
Nearly  half  of child  support agencies  (23 States) report  no birthing  hospitals  are reluctant  to 
participate  in their paternity  programs.  Of the remaining  26 States which  responded  to this 
question,  most describe  only  a few hospitals  as reluctant.  Hospital  associations  play  a role in 
19 
 encouraging  participation  in voluntary  paternity  acknowledgment  programs  in 35 States, 
according  to child  support respondents.  These  organizations  typically  send letters 
encouraging  hospitals  to participate,  and in a few cases are also involved  in staff training. 
While  both child  support  and vital  records  agencies  give moderately  high  ratings  to the 
ability  and effort  of hospital  staff in administering  acknowledgments,  vital  records  agencies 
are more  apt to assess these elements  as fair or poor. 
Vital records  and child  support agencies  generally  endorse  hospital  staff,  although 
vital  records  agencies judge  the ability  and effort  of hospital  staff somewhat  lower 
than child  support.  This  is noteworthy,  considering  vital  records  agencies  clearly 
have stronger,  on-going  relationships  with hospital  birth  registrars.  Thirty-nine  child 
support respondents  rate hospital  staff ability  as excellent  or good,  compared  with 
only  31 vital  records  agencies.  Similarly,  staff effort  is rated excellent  or good by 31 
child  support  agencies  but only  25 vital  records  agencies.  Taken  as a whole,  child 
support  and vital  records  agencies  rate hospital  staff ability  higher  than their  effort 
(See Table 7).  Based on other  study findings,  this perception  of hospital  staff 
possessing  more  ability  than the effort  they put forth  may be due more  to lack of time 
than lack of interest  on the part of hospital  staff.  Some agency  respondents  believe 
hospital  staff effort  would be greater  if there  was more  individual  accountability.  One 
child  support  agency  added the following:  . . . hospital stafs would  be more 
conscientious  about explaining  the program  if they were required to send a signed 
statement from  the mother stating that she had the program  explained  to her and that 
she chooses not to participate.   Two States currently  use such  a form  which 
requires  the mother  to sign that she has received  information  about the process  and 
chooses  not to acknowledge  paternity  in the hospital  or is unable  to do so (see 
Appendix  A-4 for an example).  Wider use by child  support agencies  of hospital 
monitoring  and assessment  procedures  may also address this issue of accountability. 
Table 7:  ABILITY AND EFFORT OF HOSPITAL STAFF 
Ability  Effort 
Child Support  Vital Records  Child Support  Vital Records 
Excellent  19%  12%  23%  7% 
(8)  (5)  (9)  (3) 
Good  76%  60%  56%  51% 
(31)  (26)  (22)  (22) 
Fair  5%  21%  18%  35% 
(2)  (9)  (7)  (15) 
Poor or Very  Poor  0%  7%  3%  7% 
(0)  (3)  (1)  (3) 
20 
 Child  support  and vital  records  agencies  disagree  regarding  the desired  role of 
hospital  staff in administering  acknowledgments. 
Child  support  and vital records  agencies  appear  undecided  about the responsibilities  of 
frontline  hospital  staff in assisting  unmarried  parents  through  the acknowledgment 
process.  Our survey  outlines  three  areas of potential  hospital  staff responsibility: 
acknowledgment  documentation;  parental  rights  and responsibilities;  and advocacy  of 
paternity  acknowledgment.  The first two are clear  responsibilities  of hospital  staff. 
Staff must help to facilitate  the documentation  of the voluntary  acknowledgment,  just 
as they  always  have with birth  registration,  and,  according  to OBRA and PRWORA, 
must also inform  parents  of their  rights  and responsibilities.  However,  agency 
respondents  did not uniformly  identify  these as appropriate  hospital  tasks. 
In regard  to hospital  staff acting  as advocates  of paternity  acknowledgment,  their 
appropriate  role  is somewhat  controversial.  Some believe  that hospital  staff should 
not actively  urge or encourage  acknowledgment,  especially  if the hospital  is being 
paid for submitting  completed  forms,  as this may jeopardize  the voluntary  nature  of 
acknowledgment.  However,  34 child  support  and 23 vital records  respondents 
support  this more proactive  role by hospital  staff (See Table 8). 
Table 8: ROLE OF HOSPITAL STAFF 
Child Support  Vital Records 
Helping to Facilitate  Paper and/or  Electronic  Documentation  96%  80% 
(49)  (40) 
informing  Parents of Their Rights and Responsibilities  90%  74% 
 
(46)  (37) 
IIA ctively  Urging and Encouraging  Parents to Acknowledge  67%  46% 
I  (34)  I  (23) 
CONTACT WITH PARENTS 
Child Support Agencies  Report that Putative Fathers  More  Often Create a Barrier  to 
Acknowledging  Paternity than Do Mothers,  and  Consider  the Parent  Relationship  to 
be the Most Important  Factor  in Choosing  to Acknowledge. 
Of the 32 State child  support offices  which  responded  to this question,  18 (56 percent) 
believe  it is most often the father  who creates  a barrier  to acknowledging  paternity, 
11 (35 percent)  report  the mother  and father  share responsibility  equally  for not 
acknowledging  and three  (nine percent)  report  the mother  as most often reluctant. 
When State child  support agencies  were asked what they  believe  guides unmarried 
parents  in choosing  to acknowledge,  a number  of factors  were selected by respondents 
as having  a strong or very  strong influence:  1) new parents  cohabitating  or in long 
relationship  (38 States); 2) emotional  feelings  with babys arrival  (37 States);  and 3) 
exposure  to idea of paternity  acknowledgment  from hospital  staff (30 States).  Factors 
21  reported  to influence  parents  not to acknowledge  include:  1) bad relationship  between 
the new parents  (42 States); 2) unmarried  father  doesnt  visit the hospital  (39 States); 
3) new mothers  fear of sharing  custody  (35 States); 4) short length  of hospital  stay 
(33 States); and 5) lack of understanding  about paternity  (30 States).  In the 
companion  report  subtitled  Hospital  Experiences  in Sample States we provide  more 
detail  on these potential  influences. 
Nearly All Child Support Agencies  Report  Conducting  Some  Type of  Outreach  to 
Unmarried Parents  on Paternity Acknowledgment. 
Forty-six  child  support agencies  conduct  education  and publicity  aimed at unmarried 
parents.  Among  States which  do outreach,  the most common  method  is a brochure 
(44 States),  followed  by a video  (23 States), and workshops  or lectures  (20 States). 
Twenty-five  States offer  these materials  in languages  other than English,  with Spanish 
being the most frequent  alternative.  These outreach  materials  are created  primarily 
by child  support agencies  at the State level  (41 States),  but many  are also developed 
by private  contractors  (14 States),  local  or regional  child  support  staff (five States), 
vital  records  agencies  (five States) and OCSE (two States).  In the companion 
report  subtitled  Best Practices  in Education  and Outreach  we will provide  details 
regarding  the variety  of educational  outreach  techniques  which  States and hospitals 
use in their  voluntary  paternity  acknowledgment  programs. 
Half  of State Outreach  Materials  to Unmarried Parents  Positively Encourage 
Paternity Acknowledgment,  While the Other Half  are  Strictly Informational. 
Beyond mapping  out the procedure  for establishing  paternity  both at-birth  and post-
birth  and listing  the rights  and responsibilities  that accompany  acknowledgment 
(including  the obligation  for child  support),  parent  outreach  brochures  typically 
address  issues such as welfare  eligibility,  custody,  genetic  testing,  status of minors, 
interstate  procedures,  and use of the fathers  surname.  A number  of States also 
choose  to address more personal  issues in their  materials,  using  a Q & A format  to 
answer questions  such as,  What  if the mother  was using birth  control?  and  Why 
should I acknowledge  if the father  and I are getting  along  and he is already  helping 
me support the child?  About half the States appear to use a very positive, 
encouraging  tone which  focuses  on the benefits  of fatherhood,  while the other  half 
offer  more  formal  materials  which primarily  detail  the legal aspects of paternity  and 
the procedures  required  for establishment.  The most frequent  title used for 
brochures,  videos  and informational  packets  is,  Paternity  Means Legal Fatherhood.   
A Small  Number  of Child Support Agencies  Follow-up  After Discharge  With 
Parents  Who Do Not Acknowledge  Paternity During  Their Hospital  Stay. 
Seven child  support offices  (14 percent)  contact  all unmarried  mothers  who do not 
acknowledge  paternity  in the hospital.  The purpose  of these contacts  is to offer 
mothers  another  opportunity  for assistance  in acknowledging  before  the birth  is 
registered.  A phone  call or letter a week or more  after dismissal  is typical.  Child 
22  support offices  most often receive  the birth  registration  information  necessary  for 
these follow-ups  from  State or local vital records  agencies.  No vital  records  agency 
reports  use of a follow-up  procedure.  As part of a demonstration  project  sponsored 
by OCSE,  the State of Colorado  contacted  all parents  who did not acknowledge 
paternity  within  60 to 90 days.  This follow-up  was conducted  irrespective  of the 
familys  child  support status,  and so, included  all unmarried  parents  who do not 
acknowledge  paternity  at birth.  However,  a number  of States have privacy  statutes 
which  would inhibit  child  support  staff from receiving  birth  registration  information 
such as phone  numbers  and addresses  from unmarried  parents  not in the child  support 
caseload. 
23 
 RECOMMENDATIONS 
Overall,  we find both child  support and vital records  agencies  are making  positive 
changes  in the implementation  of hospital-based  paternity  acknowledgment  programs. 
Both State agencies  are supportive  of the paternity  acknowledgment  effort,  appear  to 
recognize  its importance,  and are increasingly  capable  of successfully  administering 
the acknowledgment  process.  Still,  considerable  improvement  could be made in 
forging  interagency  partnerships.  Based on our findings,  we recommend  the Office of 
Child  Support  Enforcement  (OCSE) take the following  actions  to improve  the State 
operation  of in-hospital  voluntary  paternity  acknowledgment  programs.  The first and 
second recommendations  duplicate  those found  in a companion  report  on hospital 
experiences  in sample States: 
AGENCY  INTERACTION  AND  DIVISION  OF DUTIES.  Promote interagency 
collaboration,  and assure child support and vital records  agencies more clearly 
define their respective  agency roles.  Although  it is too early  to determine  which 
specific  mechanisms  are the most conducive  to effective  interagency  cooperation,  we 
find that States reporting  the best relationships  are those actively  communicating  and 
using multiple  methods  of interaction.  OCSE should provide  technical  assistance  to 
enhance  agency  interaction  and encourage  joint  problem-solving  among child  support 
and vital  records  agencies,  especially  in States not actively  communicating.  Also, 
both agencies  in a number  of States appear unclear  about their  own and each others 
responsibilities  in administering  acknowledgments.  When asked which  agency  in their 
State is primarily  responsible  for the voluntary  acknowledgment  process,  agencies  in 
nineteen  States gave different  answers.  This could create  delays  in documentation,  as 
well as gaps in service  to hospitals  and in outreach  to unmarried  parents.  OCSE 
should consider  encouraging  States to draft  a flexible  interagency  agreement  which 
would make clear the procedures  and activities  specific  to each agency,  therefore 
avoiding  possible  duplication  of effort,  developing  efficient  administrative  mechanisms 
and maximizing  the use of State and Federal  resources. 
STATEWIDE  HOSPITAL  IMPLEMENTATION  AND  ASSESSMENT.  Monitor 
Statewide hospital implementation  by assuring  all States collect acknowledgment 
data for each birthing  hospital and by encouraging  development  of hospital 
assessment procedures.  Although  nearly  all sample child  support agencies  have 
contacted  all birthing  hospitals  regarding  the Federal  mandates,  only  36 report 
complete  Statewide hospital  participation.  In addition,  we find that programs  vary 
widely  among hospitals  in States which  have achieved  Statewide compliance.  Only 
half of child  support agencies  in sample States have  implemented  hospital  monitoring 
procedures  by collecting  data on the number  of acknowledgments  received  per 
hospital  and comparing  it to the number  of nonmarital  births  each hospital  assists. 
OCSE should consider  developing  a uniform  reporting  mechanism  for States to record 
data collected  for each birthing  hospital.  OBRA requires  States at a minimum  collect 
data on hospital  nonmarital  births  and acknowledgments  received,  but States should be 
encouraged  to also assess hospital  practices  and procedures  in obtaining  these 
24  acknowledgments.  OCSE should provide  technical  assistance  to States in creating 
hospital  assessment  procedures,  and in doing  so consider  developing  assessment 
criteria  which would evaluate  the process  birthing  hospitals  use to obtain 
acknowledgments  as well as the outcome of acknowledgments  received.  Examples  of 
potential  assessment  criteria  include use of hospital  staff training  and outreach 
materials,  hospital  staff contact  with unmarried  parents,  and documentation  handling. 
Not only  are many  hospitals  often not monitored  in their  program  participation,  but 
few child  support offices  conduct  follow-up  efforts  to determine  continuing  hospital 
needs.  A uniform  State reporting  mechanism  would  serve to determine  State 
compliance  with the hospital  data collection  requirement,  and would also allow  OCSE 
to monitor  Statewide program  implementation.16 
USE  OF FUNDS.  Clarify the appropriate  use by child support agencies of 
Federal Financial  Participation  (FFP) monies in compensating  vital records 
agencies.  Of vital  records  agencies  who were paid,  a large majority  report  the 
additional  funds are beneficial,  helping  their  offices  to administer  the voluntary 
acknowledgment  process.  Additionally,  most child  support  agencies  who pay report 
better  service  and/or  an improvement  in their  interagency  relationship  with vital 
records.  But regardless  of the merit  of payments  to vital  records,  it is clear that some 
child  support agencies  are confused  about the validity  of paying  as it concerns  the use 
of FFP funds. 
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.  The Office of 
the Assistant  Secretary  for Planning  and Evaluation  provided  its general  concurrence 
with both this report  and the hospital  experiences  report. 
25 
 ENDNOTES 

1.  A Birthing hospital  is a hospital  which has an obstetric  care unit or provides 
obstetric  services,  or a birthing  center  associated  with a hospital.  (Federal 
Register,  Vol.  59, No. 246). 
2.  Payments  may be made up to $20 to birthing  hospitals  and other entities  that 
provide  prenatal  or birthing  services  for each voluntary  acknowledgment  obtained 
pursuant  to an agreement  with the child  support agency  (Federal  Register,  Vol. 59, 
No.  246). 
3.  Regulations  written  to interpret  OBRA  93 require  States to assess each birthing 
hospitals  program  on at least an annual  basis (Federal  Register,  Vol.  59, No. 
246).  This  assessment  requirement  specifies  only the collection  of data on 
nonmarital  births  assisted and acknowledgments  received  per hospital.  Following 
consultation  with OCSE,  we use in this report  the phrase  monitor  hospital 
participation  to refer  to this type of data collection.  The term  hospital 
assessment  refers  to a broader  effort  which  would include  the evaluation  of 
hospital procedures  as well as outcomes. 
4.  Surveys  were not sent to IV-D offices  in the United  States territories. 
5.  Child  support  and vital records  agency  surveys  were received  between  April  and 
August of  1996. 
6.  Child  support respondents  in about half  of these States (22) report  their pre-OBRA 
acknowledgment  services  were offered  Statewide.  See Hospital  Participation 
section  for further  discussion. 
7.  In four States,  the fee is only  applicable  after one year,  in one State after 90 days, 
and in one State the fee is waived  if the birth  is part of the child  support agency 
caseload. 
8.  Sending the copy designated  for the child  support may be at the parents  option. 
9.  In most States (85 percent),  the vital  records  agency  permanently  houses all 
original  birth  registration  documents,  serving  as the legal repository  for voluntary 
acknowledgments. 
10.  Some State child  support and vital  records  agencies use multiple  methods  for 
transmitting  documentation  information,  so percentages  equal greater  than  100. 
11.  Even when vital  records  agencies  have operational  Electronic  Birth Certificate 
systems,  their  paternity  data may be stored completely  separately  of birth 
certificate  data and therefore  not be automated. 
26 
 12. 	 The two agencies  which responded  that they didnt know  whether  or not timeliness 
was a problem  may not know because they  were answering  at the State child 
support level,  and the problem  of late information  (if it exists) could be felt more 
by the local or regional  child  support offices. 
13. 	 The discrepancies  between  child  support and vital  records  agency  responses  in the 
same categories  are due in part to a few agencies  which  responded  to the survey 
but did not answer  this particular  question,  and to different  interpretations  among 
survey  respondents  as to what is meant by scaled responses  such as informal 
communication.   
14. 	 The regulation  which  interprets  OBRA 93 indicates  the State child  support 
agencies  may enter  into agreements  with the agency  responsible  for maintaining  the 
Statewide database  in order  to obtain  identifying  information  about 
acknowledgments  recorded  in the database  and the entity  that maintains  the 
acknowledgments  in order  to obtain  authenticated  copies.  It appears  that Federal 
Financial  Participation  funds may be used for such documentation  costs (Federal 
Register,  Vol.  59, No. 246).  Because PRWORA  requires  the involvement  of vital 
records  agencies  in paternity  acknowledgment  programs,  regulations  interpreting 
the Act may redefine  the criteria  used for payment  of FFP to vital  records 
agencies. 
15. 	 Although  only  four percent  of respondents  reported  using outreach  materials 
created  by OCSE,  a number  of State-generated  materials  appeared  to have been 
developed  using OCSE materials  for guidance. 
16. 	 States already  have  incentives  for improving  their paternity  establishment  rates,  as 
PRWORA  requires  State child  support agencies  to increase  their  rates by a specific 
amount  over  the previous  year or be subject to penalties.  Additionally,  PRWORA 
requires  that the Secretary  of Health  and Human  Services  recommend  to Congress 
a new incentive  funding  system for State child  support agencies  which  is to be 
based on program  performance.  In preliminary  documents,  a joint  Workgroup of 
representatives  from  OCSE and State IV-D programs  recommended  that the 
Secretary  include  a paternity  establishment  measure  as one of five State 
performance  requirements  for receiving  incentive  funds.  The penalty  and incentive 
structures,  while  encouraging  overall  paternity  rates to increase,  do not directly 
address the issue of Statewide birthing  hospital  participation  in voluntary 
acknowledgment  programs. 
27 
 APPENDIX  A 

SAMPLE PATERNITY  ACKNOWLEDGMENT  FORMS 
INDEX: 
Paternity  Acknowledgment  Affidavit  A-2 

Three-way  Paternity  Acknowledgment  Affidavit  A-3 

Mothers  Rejection  of Paternity  Affidavit  A-4 

A-l  :  Complete  in I&  ana  da not  alter 
State  of Arkansas 
-  Name of Chrld -First. Middle. La51  Date 01 Bmh . (Month.  Day. Year,  I 
Place of Bmh  Gty.  Srate  Hosptral 
MOTHERS  INFORMATION 
Name of Mother  -Ftrst. Middle. Last  (Matden)  Date of Btrth -(Month.  Day  Year1 
Mo~hers Address  tdrreet.  Cty.  State 8 2  Coder  I Mothers  Telephone  Number 
I 
Mothers Place of Btrth (City  State)  Mothers  Soctal Secunty  Number 
Mothers Employer  r Occuoat80n llm~re .~OS,~I enr em010~mesn0r ew  1 Type of Business  or Industry  eela. s..d:
casnw egc3ea nil% iJo*,  -0lwal. Icea*eNcel Swol 
Htspantc ongm  Yes  NO  cme ow  /I yes LoeatDeOI,MBlcac,c.w DdO Rca-DC  Race -wer~dn (.~4dnsiac* ww  s:c swc8rr B~Io.~, Educatton  -rrn~awsignet!GraaeCornowed 
Mothers Medrcal Insurance  -Company  Name  Poltcy Number 
FATHERS  INFORMATION 
IName of Father -First. Middle. Last  Date of Btrth -(Month.  Day  Year! 
I 
1 
Fathers Address  (Street. Gty  State & Zip Code)   Fathers  Telephone  Number 
I 
Fathers Medlcal  insurance  -Company  Name  Policy Number 
I have read the back of thrs form and I understand  It. I certify that I am tne natural mother  I have read the back of this form and I understand  It.  I certffy  that I am the bIologica: 
and the man named above is the blological (natural1 father of this chtld  I consent to thts  (natural) father of the chtld named above  I accept the obltgation to provtde chtld supper: as 
Af!:davlt Acknowledging  Patermty.  I request that this chrlds last name be changed  lf a  de!ermmed by state law  I request that this chrlas last name be changed If a new name 6 
new name IS g!ven on the back.  given on the back. 
I
Mothers Signature  (Current  Last Name)  Fathers Stgnature  (Current  Last Name) 
Date Signed  Date Sgned 
Print Name  Pnnt Name 
State of  county  of  State of  Courty  of 
Signed and affrrmed before me on the  Signed and ahlrmed  before me on the 
Day of  19  Day of  19 
I
Slgnaiure  of Notary Publrc  Signature of Notary  Public 
My Commrsslon  expires on  My Ccmms5m  expires cn ____-~- __.  -_  ---.-
Name  City  Stare 8 Zip Code  Where Atldawt  Sgned  Name  City  State d 2~; Code  Wnere Affrdaw  Sgned 
A-2  MOTHERS  REJECTION  OF  PATERi1T-S  ,kl3?DAVIT 
I af3k-n  that  I have  been given  the option  to complete  a paw-nip  affidavit  within  the first 72 
hours  after  the birth  of my child,  that the paternity  &idavit  has bezn fkily  expkned  to me,  and I 
do  not  choose  to compIete  this form. 
I understand  that by ,oivin,o up this option  the ody  procedure  available  to me for paternity 
establishment  for the chiId(ren)  listed beIow  will  be a paternity  action  in a court  of law with 
jurisdiction  over paternity. 
_  . 
Printed  Name  of Mother 
Signature  of Mother  Date 
Printed  Name(s)  of Child(ren): 
A-4 
 LAaiohct  rUtI  riUMAN  HthdUhtCtb 
STATE  REGISTRAR  OF  VITAL  STATISTICS 
THREE-WAY  PATERNEY  AFFIDAVIT 
NON-FATHERS  AFFIDAVIT 
Pursuant  to  KRS  213.046,  I,  9 having  duly  sworn  do hereby  state  and 
affirm  that  I AM  NOT  the  natural  father  and  ail  information  relating  to  me  shall  be  removed  from  the 
birth  certificate  of  a  child,  named 
(sex)  (full name  of child  at birth) 
born  on  , 19- at  ,  f 
(hOS@td/)  (city) 
Kentucky. 
(social  security  number)  (signature  of non-father) 
Subscribed  and  sworn  to  before  me  on this  the  day  of  ,19  . 
My commission  expires  Notary 
FATHERS  AFFIDAVIT 
/ 
Pursuant  to  KRS  213.046,  I,  avin  duly  sworn  do hereby  state,
A  P 
affirm,  and  acknowledge  that  I am  the  natural  fathe  child,  named 
, 19
(fuu// name  of child at birth) 
at  , Kentucky. 
(hospital) 
My date  of  birth  is  and 
My race  is  and  I was  . 
(city andstate) 
(fathers  social  security  number)  (fatherssignature) 
Subscribed  and  sworn  to  before  me  on this  the  day  of  ,19  . 
My commission  expires  Notary 
MOTHERS  AFFIDAVIT 
I,  7 having  been  duly  sworn,  do  hereby  state,  affirm,  and  acknowledge 
that  1 am  the  natural  mother  of  the  above  said  child  and  that  , 
the  above  affiant,  is the  natural  father  of  said  child.  My maiden  name  is  . 
Childs  name  should  read  . 
(motherssociaisecuritynumber)  (motherssignature) 
Subscribed  and  sworn  to  before  me  on  this  the  day  of  ,19  -
My corn mission  expires  Notary 
A-3