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 OIG’s 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. 

OEI’s Dallas Regional Office prepared 

Inspector General. 

Project Staff included: 

DALLAS REGION 

Ruth Ann Dorrill, Project Leader 

Michelle Adams, Ph.D 

Karen Erickson, Intern 

Lisa Lesh, Intern 

Marnette Robertson 

Sarah Taylor 

Nancy Watts 

this report under the direction of Chester B. Slaughter, Regional 

HEADQUARTERS 

Arm O’Connor, Program Specialist 

Linda Moscoe 

Barbara Tedesco 

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 State’s 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 inhospital 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 Mother’s 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 IVD 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 State’s 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 hospitalbased 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 President’s 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 State’s 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 1940’s and 50’s. 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, VIand “we used paternity 

a$+idavits,but we didn’t collect data or keep track of their use per hospital. ” Many 

mentioned they “only kept forms at the public health ofSice and didn’t 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 State’s 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 

Father More Receptive to Acknowledging at Birth 

Father More Likely to Be Present at Birth than Later 

Parents Receive Exposure to Rights and Responsibilities 

Paperwork Easier Than After Hospital Dismissal 

Parents Avoid Cost and Stress of Adjudication 

Parents Avoid Fee for Amending the Birth Certificate 

Child Support Vital Records 

96% 76% 

(48) (35) 

86% 76% 

(43) (35) 

86% 48% 

(43) (22) 

80% 74% 

(40) (34) 

78% 59% 

0% (27) 

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 

May Acknowledge Without a True Understanding of Its Implications 

May Discourage Some Fathers from Visiting the Hospital 

May Lead to More Rescissions 

May Jeopardize Mom’s Custodial Rights 

May Discourage Mothers from Prenatal Care 

PRACTICES AND PROCEDURES 

Child Vital 

SUPpofi Records 

61% 78% 

(22) (25) 

31% 13% 

(11) (4) 

14% 25% 

(3 (8) 

14% 9% 

(5) (3) 

6% 100% 

(2) (45) 

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 postregistration 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 father’s 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 

support order to be established. As discussed earl 

on separate affidavit forms or may be included on 

documenting acknowledgments varies by Sta 

the vital records agency, and then to the child su 

information is received by child support offices 

methods: 1) 23 State vital records systems 

hospitals and send photocopies of these to child s 

(43 percent); 2) 18 States use a multi-copy ca 

copy typically going to the mother, one to the 

child support enforcement’, allowing both vital re 

acknowledgments directly from the hospital (34 

systems provide child support personnel with 

registration information (28 percent); 4) five 

electronic or paper list of available acknowledgm 

request copies (nine percent); and 5) in two 

acknowledgments to child support and original dot 

percent) .9*10 

ital to the child support agency for a 

acknowledgments may be completed 

e birth certificate itself. The path of 

ally goes from birthing hospitals to 

rt office. Acknowledgment 

one or more of the following basic 

wledgments from birthing 

ort, either automatically or by request 

ss paternity affidavit form, with one 

, one to vital records and a fourth to 

s and child support to receive 

nt); 3) 15 State vital records 

access to paternity and birth 

ital records systems create an 

s from which child support may 

1s send photocopies of 

ents to vital records (four 

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 

agencies all report plans to go “paperless, ” 

receive only paper documentation of paternity 

stated above, child support respondents in 13 State 

information on-line. One method of 

transfer information upon request or 

a smaller database shared by child support offices. 

the remaining vital records 

of child support offices still 

from vital records. l1 As 

(28 percent) are able to access 

records agencies to 

the primary public health database to 

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 record’s 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 State’s 

procedures, it shouldn’t 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 didn’t 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 asreceived. 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 child’s name and parent’s 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 father’s and mother’s 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 mother’s name (24 States), father’s name (23 

States) and child’s name (22 States). Other matching information includes child’s date of 

birth, mother’s and father’s Social Security Numbers, and mother’s 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 Other’s 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 State’s 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 State’s voluntary acknowledgment program and receives only the birth 

certificates for registration. Nationwide, however, only three States report their child 

support agency houses their State’s 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 

Communication Between Key Personnel 

Informal Staff Communication 

Shared Training Efforts for Hospital Staff 

Interagency Agreement 

Shared Automated Database 

Joint Agency Committee or Task Force 

Shared Training Efforts for Parents 

Child Support 

86% 

(44) 

77% 

(3% 

51% 

(26) 

39% 

(20) 

37% 

(1% 

18% 

(9) 

14% 

(7) 

Vital Records 

71% 

(36) 

75% 

(38) 

51% 

(26) 

47% 

(24) 

35% 

(18) 

16% 

(8) 

12% 

(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 

Brochures/Pamphlets 

On-site Lectures or Seminars 

Other (examples: regional workshops, individual 

meetings, l-800 numbers, etc.) 

Training Video 

Child Support Vital Records 

89% 54% 

(41) (26) 

67% 71% 

(31) (34) 

65% 40% 

(30) (1% 

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 

No Barriers to Interagency Cooperation 

Differences in Automation 

Little or No Funds from Child Support 

Agency to Vital Records Agency 

Inflexibility by One Or Both Agencies 

Statutory Conflict 

Unclear About Relative Agency Responsibilities 

Poor Communication 

Child Support Vital Records 

31% 27% 

(15) (13) 

45% 12% 

(22) (6) 

25% 54% 

(12) (26) 

25% 8% 

(12) (4) 

16% 17% 

63) (8) 

12% 25% 

(6) (12) 

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 agency’s 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 don’t 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 hospital’s job to process birth 

registration information and therefore they shouldn’t 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 State’s 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 couldn’t 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 

No Barriers Found 

HospitaI Understaffed to Deal with the Acknowledgment Process 

Staff Doesn’t Recognize the Importance of Their Role 

Staff is Inflexible and Resistant to Change 

Little or No Payment to Hospitals by Child Support Agency 

Child Support Vital Records 

22% 20% 

(11) (10) 

64% 63% 

(32) (31) 

46% 20% 

(23 (10) 

20% 8% 

(10) (4) 

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 Unmam’ed 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 

II 

Helping to Facilitate Paper and/or Electronic Documentation 96% 80% 

(49) (40) 

�  informing Parents of Their Rights and Responsibilities 90% 74% 

(46) (37) 

Actively 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 baby’s 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 doesn’t visit the hospital (39 States); 

3) new mother’s 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 postbirth 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 father’s 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 

family’s 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 other’s 

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. 

2. 

3. 

4. 

5. 

6. 

7. 

8. 

9. 

10. 

11. 

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). 

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). 

Regulations written to interpret OBRA ‘93 require States to “assess” each birthing 

hospital’s 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. 

Surveys were not sent to IV-D offices in the United States territories. 

Child support and vital records agency surveys were received between April and 

August of 1996. 

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. 

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. 

Sending the copy designated for the child support may be at the parents’ option. 

In most States (85 percent), the vital records agency permanently houses all 

original birth registration documents, serving as the legal repository for voluntary 

acknowledgments. 

Some State child support and vital records agencies use multiple methods for 

transmitting documentation information, so percentages equal greater than 100. 

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 didn’t 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 

Mother’s 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 

MOTHER’S INFORMATION 

Name of Mother - Ftrst. Middle. Last (Matden) Date of Btrth - (Month. Day Year1 

Mo~her’s Address tdrreet. Cty. State 8 2’ Coder I Mother’s Telephone Number 

I 

Mother’s Place of Btrth (City State) Mother’s Soctal Secunty Number 

Mother’s Employer r Occuoat80n llm~re .~OSI ,~enr em010~menr s0ew 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 Loeat”DeOI,MB‘lca”c,c.w Dd”O Rca- DC Race - wer~dn (.~4dnsiac* ww s:c swc8rr B~Io.~, Educatton - rrn~awsignet!GraaeCornowed 

Mother’s Medrcal Insurance - Company Name Poltcy Number 

FATHER’S INFORMATION 

I

Name of Father - First. Middle. Last Date of Btrth - (Month. Day Year! 

I 1 

Father’s Address (Street. Gty State & Zip Code) ’ Father’s Telephone Number 

I 

Father’s 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 chrld’s last name be changed lf a de!ermmed by state law I request that this chrla’s last name be changed If a new name 6 new name IS g!ven on the back. given on the back. 

I

Mother’s Signature (Current Last Name) Father’s 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 
MOTHER’S REJECTION OF PATER”i1T-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 PATERNE’Y AFFIDAVIT 

NON-FATHER’S 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 

FATHER’S 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) 

(father’s social security number) (father’ssignature) 

Subscribed and sworn to before me on this the day of ,19 . 

My commission expires Notary 

MOTHER’S 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 . 

Child’s name should read . 

(mother’ssociaisecuritynumber) (mother’ssignature) 

Subscribed and sworn to before me on this the day of ,19 -

My corn mission expires Notary 

A-3