\r\n\r\n\r\n\r\n","import mod from \"-!../../node_modules/cache-loader/dist/cjs.js??ref--12-0!../../node_modules/thread-loader/dist/cjs.js!../../node_modules/babel-loader/lib/index.js!../../node_modules/cache-loader/dist/cjs.js??ref--0-0!../../node_modules/vue-loader/lib/index.js??vue-loader-options!./Address.vue?vue&type=script&lang=js&\"; export default mod; export * from \"-!../../node_modules/cache-loader/dist/cjs.js??ref--12-0!../../node_modules/thread-loader/dist/cjs.js!../../node_modules/babel-loader/lib/index.js!../../node_modules/cache-loader/dist/cjs.js??ref--0-0!../../node_modules/vue-loader/lib/index.js??vue-loader-options!./Address.vue?vue&type=script&lang=js&\"","import { render, staticRenderFns } from \"./Address.vue?vue&type=template&id=d70e77b6&\"\nimport script from \"./Address.vue?vue&type=script&lang=js&\"\nexport * from \"./Address.vue?vue&type=script&lang=js&\"\n\n\n/* normalize component */\nimport normalizer from \"!../../node_modules/vue-loader/lib/runtime/componentNormalizer.js\"\nvar component = normalizer(\n script,\n render,\n staticRenderFns,\n false,\n null,\n null,\n null\n \n)\n\nexport default component.exports\n\n/* vuetify-loader */\nimport installComponents from \"!../../node_modules/vuetify-loader/lib/runtime/installComponents.js\"\nimport { VAutocomplete } from 'vuetify/lib/components/VAutocomplete';\nimport { VContainer } from 'vuetify/lib/components/VGrid';\nimport { VFlex } from 'vuetify/lib/components/VGrid';\nimport { VLayout } from 'vuetify/lib/components/VGrid';\nimport { VTextField } from 'vuetify/lib/components/VTextField';\ninstallComponents(component, {VAutocomplete,VContainer,VFlex,VLayout,VTextField})\n","export * from \"-!../../node_modules/mini-css-extract-plugin/dist/loader.js??ref--6-oneOf-1-0!../../node_modules/css-loader/index.js??ref--6-oneOf-1-1!../../node_modules/vue-loader/lib/loaders/stylePostLoader.js!../../node_modules/postcss-loader/src/index.js??ref--6-oneOf-1-2!../../node_modules/cache-loader/dist/cjs.js??ref--0-0!../../node_modules/vue-loader/lib/index.js??vue-loader-options!./MothersWorksheet.vue?vue&type=style&index=0&id=031caf93&scoped=true&lang=css&\"","var render = function () {var _vm=this;var _h=_vm.$createElement;var _c=_vm._self._c||_h;return _c('v-container',{attrs:{\"fluid\":\"\",\"px-3\":\"\",\"pt-3\":\"\"}},[_c('v-row',{attrs:{\"row\":\"\",\"wrap\":\"\"}},[_c('v-col',{attrs:{\"cols\":\"12\"}},[_c('h3',[_vm._v(\"MOTHER'S WORKSHEET FOR CHILD'S BIRTH CERTIFICATE\")]),_c('v-divider')],1),(!_vm.isSaved && !_vm.isSubmitted)?_c('v-col',{attrs:{\"cols\":\"12\"}},[_vm._v(\"\\n The information you provide below will be used to complete your child’s birth certificate.\\n The birth certificate is a document that will be used for legal purposes to prove your child’s age, citizenship, and parentage.\\n Your child throughout his or her life will use the information from this document.\\n Please take care to answer each question as accurately as possible.\\n If you have a problem with some of the questions, please ask the birth certificate clerk in the hospital for assistance.\"),_c('br')]):_vm._e()],1),_c('v-row',[_c('v-col',[(_vm.isLoading)?_c('v-progress-circular',{attrs:{\"indeterminate\":\"\",\"size\":65,\"width\":5}}):_vm._e()],1),_c('v-col',[(_vm.mothersWorksheetDto.completed)?_c('div',[_c('b',{staticStyle:{\"color\":\"red\",\"font-size\":\"large\"}},[_vm._v(\"SUBMITTED\")])]):_vm._e()])],1),_c('v-row',{directives:[{name:\"show\",rawName:\"v-show\",value:(!_vm.isSaved && !_vm.isSubmitted && !_vm.isLoading),expression:\"!isSaved && !isSubmitted && !isLoading\"}],attrs:{\"row\":\"\",\"wrap\":\"\"}},[_c('v-col',[_c('v-card',[_c('v-form',{ref:\"mothersWorksheetForm\",model:{value:(_vm.formValid),callback:function ($$v) {_vm.formValid=$$v},expression:\"formValid\"}},[_c('v-container',[_c('b',{staticStyle:{\"color\":\"red\"}},[_vm._v(\"* Denotes a required field.\")]),_c('v-row',[_c('v-col',{attrs:{\"cols\":\"12\"}},[_c('b',[_vm._v(\"1. Child's Name\"),_c('b',{staticStyle:{\"color\":\"red\"}},[_vm._v(\"*\")]),_vm._v(\" - \")]),_vm._v(\"\\n This should be the name that child will use throughout life.\\n The child’s given first and middle names may be changed within one year of the date of birth.\\n \"),_c('b',[_vm._v(\"The last name(s) entered here may only be changed by court order or by an Affidavit Acknowledging paternity.\")])])],1),_c('v-row',[_c('v-col',[_c('name',{ref:\"childNameRef\",attrs:{\"isRequired\":true},model:{value:(_vm.mothersWorksheetDto.childName),callback:function ($$v) {_vm.$set(_vm.mothersWorksheetDto, \"childName\", $$v)},expression:\"mothersWorksheetDto.childName\"}})],1)],1),_c('v-row',[_c('v-col',{attrs:{\"cols\":\"12\"}},[_c('b',[_vm._v(\"2. Mother's Current Legal Name\"),_c('b',{staticStyle:{\"color\":\"red\"}},[_vm._v(\"*\")]),_vm._v(\" -\")])])],1),_c('v-row',{attrs:{\"align\":\"center\"}},[_c('v-col',{attrs:{\"cols\":\"12\"}},[_c('name',{ref:\"mothersLegalNameRef\",attrs:{\"isRequired\":true},model:{value:(_vm.mothersWorksheetDto.mothersLegalName),callback:function ($$v) {_vm.$set(_vm.mothersWorksheetDto, \"mothersLegalName\", $$v)},expression:\"mothersWorksheetDto.mothersLegalName\"}})],1),_c('v-col',{attrs:{\"cols\":\"6\"}},[_c('b',[_vm._v(\"List additional surnames if applicable. Note - some countries require surnames of both parents for dual citizenship -\")])]),_c('v-col',{attrs:{\"cols\":\"6\"}},[_c('v-text-field',{attrs:{\"label\":\"Surname\"},model:{value:(_vm.mothersWorksheetDto.mothersLegalNameLast2),callback:function ($$v) {_vm.$set(_vm.mothersWorksheetDto, \"mothersLegalNameLast2\", $$v)},expression:\"mothersWorksheetDto.mothersLegalNameLast2\"}})],1)],1),_c('v-row',{attrs:{\"align\":\"center\"}},[_c('v-col',{attrs:{\"cols\":\"6\"}},[_c('b',[_vm._v(\"3. Mother's Date of Birth\"),_c('b',{staticStyle:{\"color\":\"red\"}},[_vm._v(\"*\")]),_vm._v(\" -\")])]),_c('v-col',{attrs:{\"cols\":\"6\"}},[_c('v-text-field',{ref:\"momBirthRef\",attrs:{\"label\":\"Birthdate\",\"type\":\"date\",\"required\":\"\",\"rules\":_vm.requiredDateRule},model:{value:(_vm.mothersWorksheetDto.momDateOfBirth),callback:function ($$v) {_vm.$set(_vm.mothersWorksheetDto, \"momDateOfBirth\", $$v)},expression:\"mothersWorksheetDto.momDateOfBirth\"}})],1)],1),_c('v-row',[_c('v-col',{attrs:{\"cols\":\"12\"}},[_c('b',[_vm._v(\"4. Mother's Name Before First Marriage (Maiden Name)\"),_c('b',{staticStyle:{\"color\":\"red\"}},[_vm._v(\"*\")]),_vm._v(\" -\")])])],1),_c('v-row',[_c('v-col',{attrs:{\"cols\":\"12\"}},[_c('name',{ref:\"mothersPriorNameRef\",attrs:{\"isRequired\":true},model:{value:(_vm.mothersWorksheetDto.mothersPriorName),callback:function ($$v) {_vm.$set(_vm.mothersWorksheetDto, \"mothersPriorName\", $$v)},expression:\"mothersWorksheetDto.mothersPriorName\"}})],1)],1),_c('v-row',[_c('v-col',{attrs:{\"cols\":\"12\"}},[_c('b',[_vm._v(\"5. Mother's Place of Birth\"),_c('b',{staticStyle:{\"color\":\"red\"}},[_vm._v(\"*\")]),_vm._v(\" - \")]),_vm._v(\"Select the U.S. State, U.S. Territory, or Foreign Country:\\n \")])],1),_c('v-row',{attrs:{\"align\":\"center\"}},[_c('v-col',{attrs:{\"cols\":\"6\"}},[_c('v-select',{attrs:{\"required\":\"\",\"rules\":_vm.requiredDateRule,\"items\":_vm.countries,\"item-value\":\"id\",\"item-text\":\"description\",\"label\":\"Birth Country\"},on:{\"change\":function($event){return _vm.getStatesOrTerritoriesMother()}},model:{value:(_vm.mothersWorksheetDto.momBirthCountryId),callback:function ($$v) {_vm.$set(_vm.mothersWorksheetDto, \"momBirthCountryId\", $$v)},expression:\"mothersWorksheetDto.momBirthCountryId\"}})],1),(_vm.mothersWorksheetDto.momBirthCountryId == 377 || _vm.mothersWorksheetDto.momBirthCountryId == 152)?_c('v-col',{attrs:{\"cols\":\"6\"}},[_c('v-select',{attrs:{\"items\":_vm.motherStates,\"item-value\":\"id\",\"item-text\":\"description\",\"label\":\"Birth State, Province, or Territory\"},model:{value:(_vm.mothersWorksheetDto.momBirthStateId),callback:function ($$v) {_vm.$set(_vm.mothersWorksheetDto, \"momBirthStateId\", $$v)},expression:\"mothersWorksheetDto.momBirthStateId\"}})],1):_vm._e()],1),_c('v-row',[_c('v-col',{attrs:{\"cols\":\"12\"}},[_c('b',[_vm._v(\"6. Mother's Residence, Address, and Contact Information\"),_c('b',{staticStyle:{\"color\":\"red\"}},[_vm._v(\"*\")]),_vm._v(\" - \")]),_vm._v(\"\\n This should be the place at which the mother has set up housekeeping.\\n \"),_c('b',[_vm._v(\"It is not to be a temporary residence used during a visit or vacation.\")]),_vm._v(\"\\n Residence during a tour of military duty or during attendance at college should be entered.\\n \")])],1),_c('v-row',[_c('v-col',[_c('addr',{ref:\"mothersResidenceRef\",attrs:{\"id\":\"mothersResidence\",\"isRequired\":true},model:{value:(_vm.mothersWorksheetDto.residence),callback:function ($$v) {_vm.$set(_vm.mothersWorksheetDto, \"residence\", $$v)},expression:\"mothersWorksheetDto.residence\"}})],1)],1),_c('v-row',{attrs:{\"align\":\"center\"}},[_c('v-col',{attrs:{\"cols\":\"6\"}},[_c('b',[_vm._v(\"Is this residence inside the city limits?\"),_c('b',{staticStyle:{\"color\":\"red\"}},[_vm._v(\"*\")])])]),_c('v-col',{attrs:{\"cols\":\"3\"}},[_c('v-checkbox',{attrs:{\"label\":\"YES\"},model:{value:(_vm.insideLimitsYes),callback:function ($$v) {_vm.insideLimitsYes=$$v},expression:\"insideLimitsYes\"}})],1),_c('v-col',{attrs:{\"cols\":\"3\"}},[_c('v-checkbox',{attrs:{\"label\":\"NO\"},model:{value:(_vm.insideLimitsNo),callback:function ($$v) {_vm.insideLimitsNo=$$v},expression:\"insideLimitsNo\"}})],1)],1),_c('v-row',{attrs:{\"align\":\"center\"}},[_c('v-col',{attrs:{\"cols\":\"6\"}},[_c('b',[_vm._v(\"Mother's Primary Telephone/Cellular Phone Number\"),_c('b',{staticStyle:{\"color\":\"red\"}},[_vm._v(\"*\")]),_vm._v(\" - \")])]),_c('v-col',{attrs:{\"cols\":\"6\"}},[_c('v-text-field',{attrs:{\"required\":\"\",\"rules\":_vm.requiredRule,\"label\":\"Mother's Phone #\",\"placeholder\":\"(999) 000 0000\"},model:{value:(_vm.mothersWorksheetDto.momPhone),callback:function ($$v) {_vm.$set(_vm.mothersWorksheetDto, \"momPhone\", $$v)},expression:\"mothersWorksheetDto.momPhone\"}})],1),_c('v-col',{attrs:{\"cols\":\"6\"}},[_c('b',[_vm._v(\"Mother's Email Address\"),_c('b',{staticStyle:{\"color\":\"red\"}},[_vm._v(\"*\")]),_vm._v(\" -\")])]),_c('v-col',{attrs:{\"cols\":\"6\"}},[_c('v-text-field',{attrs:{\"required\":\"\",\"rules\":_vm.requiredRule,\"label\":\"Mother's Email\",\"placeholder\":\"name@example.com\"},model:{value:(_vm.mothersWorksheetDto.momEmail),callback:function ($$v) {_vm.$set(_vm.mothersWorksheetDto, \"momEmail\", $$v)},expression:\"mothersWorksheetDto.momEmail\"}})],1)],1),_c('v-row',{attrs:{\"align\":\"center\"}},[_c('v-col',{attrs:{\"cols\":\"12\"}},[_c('b',[_vm._v(\"7. \"),_c('u',[_vm._v(\"Mother's Marital Status\"),_c('b',{staticStyle:{\"color\":\"red\"}},[_vm._v(\"*\")]),_vm._v(\" -\"),_c('b',{staticStyle:{\"color\":\"red\"}},[_vm._v(\" VERY IMPORTANT \")])]),_vm._v(\"- ITEMS 7 AND 8 ESTABLISH \"),_c('u',[_vm._v(\"PATERNITY\")]),_vm._v(\" FOR THE CHILD.\")])]),_c('v-col',{attrs:{\"cols\":\"6\"}},[_c('b',[_vm._v(\"a. Was the Mother \"),_c('b',{staticStyle:{\"color\":\"red\"}},[_c('u',[_vm._v(\"married to anyone\")])]),_vm._v(\" within the 300 days prior to birth?\")])]),_c('v-col',{attrs:{\"cols\":\"6\"}},[_c('v-select',{attrs:{\"items\":_vm.yesNoMarried,\"item-value\":\"id\",\"item-text\":\"description\",\"required\":\"\",\"rules\":_vm.requiredDateRule},model:{value:(_vm.mothersWorksheetDto.marriedYN),callback:function ($$v) {_vm.$set(_vm.mothersWorksheetDto, \"marriedYN\", $$v)},expression:\"mothersWorksheetDto.marriedYN\"}})],1)],1),(_vm.mothersWorksheetDto.marriedYN == '1')?_c('v-row',{attrs:{\"align\":\"center\"}},[_c('v-col',{attrs:{\"cols\":\"6\"}},[_c('b',[_vm._v(\"b. If \"),_c('a',{staticStyle:{\"color\":\"red\"}},[_vm._v(\"YES\")]),_vm._v(\", is the spouse the father/parent of the child?\")])]),_c('v-col',{attrs:{\"cols\":\"6\"}},[_c('v-select',{attrs:{\"items\":_vm.yesNoSpouseFather,\"item-value\":\"id\",\"item-text\":\"description\"},model:{value:(_vm.mothersWorksheetDto.husbandFatherYN),callback:function ($$v) {_vm.$set(_vm.mothersWorksheetDto, \"husbandFatherYN\", $$v)},expression:\"mothersWorksheetDto.husbandFatherYN\"}})],1)],1):_vm._e(),(_vm.mothersWorksheetDto.marriedYN == '2' || _vm.mothersWorksheetDto.husbandFatherYN == '2')?_c('v-row',{attrs:{\"align\":\"center\"}},[_c('v-col',{attrs:{\"cols\":\"12\"}},[_c('b',[_vm._v(\"8. \"),_c('u',[_vm._v(\"Paternity Acknowledgement\")]),_vm._v(\" - Complete if the mother \"),_c('b',{staticStyle:{\"color\":\"red\"}},[_c('u',[_vm._v(\"was not married\")])]),_vm._v(\" to the child’s natural/biological father.\")])]),_c('v-col',{attrs:{\"cols\":\"6\"}},[_c('b',[_vm._v(\"a. Has the natural/biological father signed an Affidavit Acknowledging Paternity?\")])]),_c('v-col',{attrs:{\"cols\":\"6\"}},[_c('v-select',{attrs:{\"items\":_vm.yesNo,\"item-value\":\"id\",\"item-text\":\"description\"},model:{value:(_vm.mothersWorksheetDto.affidavitYN),callback:function ($$v) {_vm.$set(_vm.mothersWorksheetDto, \"affidavitYN\", $$v)},expression:\"mothersWorksheetDto.affidavitYN\"}})],1),(_vm.mothersWorksheetDto.marriedYN == 1)?[_c('v-col',{attrs:{\"cols\":\"6\"}},[_c('b',[_vm._v(\"b. If the mother was married, has her husband/spouse signed an affidavit \"),_c('u',[_vm._v(\"denying \")]),_vm._v(\"paternity?\")])]),_c('v-col',{attrs:{\"cols\":\"6\"}},[_c('v-select',{attrs:{\"items\":_vm.yesNo,\"item-value\":\"id\",\"item-text\":\"description\"},model:{value:(_vm.mothersWorksheetDto.denialYN),callback:function ($$v) {_vm.$set(_vm.mothersWorksheetDto, \"denialYN\", $$v)},expression:\"mothersWorksheetDto.denialYN\"}})],1)]:_vm._e(),_c('v-col',{attrs:{\"cols\":\"12\"}},[_vm._v(\"\\n For more information about paternity acknowledgement:\\n \"),_c('v-btn',{staticClass:\"text-only\",on:{\"click\":function($event){return _vm.openAffidavitPage()}}},[_vm._v(\"Affidavit Info\")])],1)],2):_vm._e(),_c('v-row',[_c('v-col',{attrs:{\"cols\":\"12\"}},[_c('b',[_vm._v(\"9. Father/Parent's Current Legal Name - \")]),_vm._v(\" If the mother was unmarried throughout her pregnancy, a \"),_c('u',[_vm._v(\"father\")]),_vm._v(\" may only be\\n named if an Affidavit Acknowledging Paternity is signed. If the mother was married at any time during the pregnancy\\n (300 days prior to birth), the name of the \"),_c('u',[_vm._v(\"spouse\")]),_c('b',[_vm._v(\" must\")]),_vm._v(\" be entered as the father/parent unless the natural/biological father\\n signs an Affidavit Acknowledging Paternity. If the \"),_c('u',[_vm._v(\"spouse\")]),_vm._v(\" does not sign an affidavit \"),_c('u',[_vm._v(\"denying \")]),_vm._v(\"paternity, contact Vital\\n Statistics Services immediately for guidance on completing the filing. The affidavit forms may be obtained from the birth\\n certificate clerk.\\n \")])],1),_c('v-row',[_c('v-col',{attrs:{\"cols\":\"12\"}},[_c('name',{ref:\"otherNameRef\",attrs:{\"isRequired\":_vm.otherParentInfoRequired},model:{value:(_vm.mothersWorksheetDto.otherName),callback:function ($$v) {_vm.$set(_vm.mothersWorksheetDto, \"otherName\", $$v)},expression:\"mothersWorksheetDto.otherName\"}})],1)],1),_c('v-row',{attrs:{\"align\":\"center\"}},[_c('v-col',{attrs:{\"cols\":\"6\"}},[_c('b',[_vm._v(\"List additional surnames if applicable. Note - some countries require surnames of both parents for dual citizenship -\")])]),_c('v-col',{attrs:{\"cols\":\"6\"}},[_c('v-text-field',{attrs:{\"label\":\"Surname\"},model:{value:(_vm.mothersWorksheetDto.otherNameLast2),callback:function ($$v) {_vm.$set(_vm.mothersWorksheetDto, \"otherNameLast2\", $$v)},expression:\"mothersWorksheetDto.otherNameLast2\"}})],1)],1),_c('v-row',{attrs:{\"align\":\"center\"}},[_c('v-col',{attrs:{\"cols\":\"6\"}},[_c('b',[_vm._v(\"10. Father/Parent's Date of Birth - \")])]),_c('v-col',{attrs:{\"cols\":\"6\"}},[_c('v-text-field',{attrs:{\"label\":\"Birthdate\",\"validate-on-blur\":\"\",\"type\":\"date\",\"required\":\"\",\"rules\":[_vm.otherParentRule(_vm.mothersWorksheetDto.otherDateOfBirth)]},model:{value:(_vm.mothersWorksheetDto.otherDateOfBirth),callback:function ($$v) {_vm.$set(_vm.mothersWorksheetDto, \"otherDateOfBirth\", $$v)},expression:\"mothersWorksheetDto.otherDateOfBirth\"}})],1)],1),_c('v-row',{attrs:{\"align\":\"center\"}},[_c('v-col',{attrs:{\"cols\":\"12\"}},[_c('b',[_vm._v(\"11. Father/Parent's Place of Birth - \")]),_vm._v(\"Select the U.S. State, U.S. Territory, or Foreign Country:\\n \")]),_c('v-col',{attrs:{\"cols\":\"6\"}},[_c('v-select',{attrs:{\"items\":_vm.countries,\"item-text\":\"description\",\"item-value\":\"id\",\"label\":\"Birth Country\",\"required\":\"\",\"rules\":[_vm.otherParentRule(_vm.mothersWorksheetDto.otherBirthCountryId)]},on:{\"change\":function($event){return _vm.getStatesOrTerritoriesFather()}},model:{value:(_vm.mothersWorksheetDto.otherBirthCountryId),callback:function ($$v) {_vm.$set(_vm.mothersWorksheetDto, \"otherBirthCountryId\", $$v)},expression:\"mothersWorksheetDto.otherBirthCountryId\"}})],1),(_vm.mothersWorksheetDto.otherBirthCountryId == 377 || _vm.mothersWorksheetDto.otherBirthCountryId == 152)?_c('v-col',{attrs:{\"cols\":\"6\"}},[_c('v-select',{attrs:{\"items\":_vm.fatherStates,\"item-value\":\"id\",\"item-text\":\"description\",\"label\":\"Birth State, Province, or Territory\",\"required\":\"\",\"rules\":[_vm.otherParentRule(_vm.mothersWorksheetDto.otherBirthStateId)]},model:{value:(_vm.mothersWorksheetDto.otherBirthStateId),callback:function ($$v) {_vm.$set(_vm.mothersWorksheetDto, \"otherBirthStateId\", $$v)},expression:\"mothersWorksheetDto.otherBirthStateId\"}})],1):_vm._e()],1),_c('v-row',[_c('v-col',{attrs:{\"cols\":\"12\"}},[_c('b',[_vm._v(\"12. Mother's Mailing Address and Contact Information -\")]),_vm._v(\" If same as Residence Address, skip to question 13.\\n \")])],1),_c('v-row',[_c('v-col',[_c('addr',{ref:\"mothersMailingAddressRef\",model:{value:(_vm.mothersWorksheetDto.mailingAddress),callback:function ($$v) {_vm.$set(_vm.mothersWorksheetDto, \"mailingAddress\", $$v)},expression:\"mothersWorksheetDto.mailingAddress\"}})],1)],1),_c('v-row',{attrs:{\"align\":\"start\"}},[_c('v-col',{attrs:{\"cols\":\"12\"}},[_c('b',[_vm._v(\"13. Information Released to Obtain a Social Security Number?\"),_c('b',{staticStyle:{\"color\":\"red\"}},[_vm._v(\"*\")])]),_vm._v(\"\\n Check \\\"YES\\\" if the parents wish to have information released from this form to the Social Security Administration to assign a Social Security number to this child.\\n \")]),_c('v-col',{attrs:{\"cols\":\"8\"}},[_c('b',{staticStyle:{\"color\":\"red\"}},[_vm._v(\"A Social Security card for the child will be sent directly to the Mother’s Mailing Address\")])]),_c('v-col',{attrs:{\"cols\":\"2\"}},[_c('v-checkbox',{attrs:{\"label\":\"YES\"},model:{value:(_vm.releaseSocialYes),callback:function ($$v) {_vm.releaseSocialYes=$$v},expression:\"releaseSocialYes\"}})],1),_c('v-col',{attrs:{\"cols\":\"2\"}},[_c('v-checkbox',{attrs:{\"label\":\"NO\"},model:{value:(_vm.releaseSocialNo),callback:function ($$v) {_vm.releaseSocialNo=$$v},expression:\"releaseSocialNo\"}})],1),_c('v-col',{attrs:{\"cols\":\"12\"}},[_c('b',[_vm._v(\"14. Information Released to Wyoming Department of Health Public Health Nurse County Services?\")])]),_c('v-col',{attrs:{\"cols\":\"10\"}},[_vm._v(\"\\n A Public Health Nurse Representative will contact mothers to provide information regarding services available in her community.\\n Check “NO” if the mother does NOT want to obtain information regarding services provided by Public Health Nursing in her community.\\n \")]),_c('v-col',{attrs:{\"cols\":\"2\"}},[_c('v-checkbox',{staticStyle:{\"align\":\"center\"},attrs:{\"label\":\"NO\"},model:{value:(_vm.refuseCountyServices),callback:function ($$v) {_vm.refuseCountyServices=$$v},expression:\"refuseCountyServices\"}})],1)],1),_c('v-row',[_c('v-col',{attrs:{\"cols\":\"12\"}},[_c('b',[_vm._v(\"15. Parents' Social Security Numbers\"),_c('b',{staticStyle:{\"color\":\"red\"}},[_vm._v(\"*\")]),_vm._v(\" -\")])]),_c('v-col',{attrs:{\"cols\":\"12\"}},[_vm._v(\"\\n Furnishing the parents’ Social Security Numbers is required by Federal Law, 42 USC 405(c) (section205(c) of the Social Security Act).\\n The numbers will be made available to the Wyoming Department of Family Services to assist with child support enforcement activities and to the Internal Revenue Service for the purpose of determining Earned Income Tax Credit compliance.\\n \")])],1),_c('v-row',{attrs:{\"align\":\"center\"}},[_c('v-col',{attrs:{\"cols\":\"4\"}},[_c('b',[_vm._v(\"Mother's SSN\")])]),_c('v-col',{attrs:{\"cols\":\"6\"}},[_c('v-text-field',{attrs:{\"label\":\"Example NNN-NN-NNNN\",\"required\":\"\",\"rules\":_vm.ssnRule},model:{value:(_vm.mothersWorksheetDto.mothersSSN),callback:function ($$v) {_vm.$set(_vm.mothersWorksheetDto, \"mothersSSN\", $$v)},expression:\"mothersWorksheetDto.mothersSSN\"}})],1),_c('v-col',{attrs:{\"cols\":\"2\"}},[_c('v-checkbox',{staticStyle:{\"align\":\"center\"},attrs:{\"label\":\"No SSN\"},model:{value:(_vm.noSSNMother),callback:function ($$v) {_vm.noSSNMother=$$v},expression:\"noSSNMother\"}})],1),_c('v-col',{attrs:{\"cols\":\"4\"}},[_c('b',[_vm._v(\"Father/Parent's SSN\")])]),_c('v-col',{attrs:{\"cols\":\"6\"}},[_c('v-text-field',{attrs:{\"label\":\"Example NNN-NN-NNNN\",\"required\":\"\",\"rules\":[_vm.otherParentRule(_vm.mothersWorksheetDto.otherSSN), _vm.otherParentSSNRule(_vm.mothersWorksheetDto.otherSSN)]},model:{value:(_vm.mothersWorksheetDto.otherSSN),callback:function ($$v) {_vm.$set(_vm.mothersWorksheetDto, \"otherSSN\", $$v)},expression:\"mothersWorksheetDto.otherSSN\"}})],1),_c('v-col',{attrs:{\"cols\":\"2\"}},[_c('v-checkbox',{staticStyle:{\"align\":\"center\"},attrs:{\"label\":\"No SSN\"},model:{value:(_vm.noSSNOther),callback:function ($$v) {_vm.noSSNOther=$$v},expression:\"noSSNOther\"}})],1)],1),_c('v-divider'),_c('v-row',{attrs:{\"row\":\"\",\"wrap\":\"\"}},[_c('v-col',{attrs:{\"cols\":\"12\"}},[_vm._v(\"\\n The following information is needed to compile statistics to be used for planning and evaluating health programs for expectant mothers and newborn infants. It will not be included on certified copies of the birth certificate.\\n \")])],1),_c('v-row',[_c('v-col',{attrs:{\"cols\":\"12\"}},[_c('b',[_vm._v(\"16. Mother's Education\"),_c('b',{staticStyle:{\"color\":\"red\"}},[_vm._v(\"*\")]),_vm._v(\" - \")]),_vm._v(\"\\n Select the item that best describes the highest degree or level of school completed at the time of delivery.\\n \")])],1),_c('v-row',[_c('v-col',{attrs:{\"cols\":\"12\"}},[_c('v-select',{attrs:{\"items\":_vm.educationTypes,\"item-text\":\"description\",\"item-value\":\"id\",\"label\":\"Education Level\",\"required\":\"\",\"rules\":_vm.requiredDateRule},model:{value:(_vm.mothersWorksheetDto.educationId),callback:function ($$v) {_vm.$set(_vm.mothersWorksheetDto, \"educationId\", $$v)},expression:\"mothersWorksheetDto.educationId\"}})],1)],1),_c('v-row',{attrs:{\"align\":\"center\"}},[_c('v-col',{attrs:{\"cols\":\"12\"}},[_c('b',[_vm._v(\"17. 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{_vm.$set(_vm.mothersWorksheetDto.otherRace, \"nativeHawaiin\", $$v)},expression:\"mothersWorksheetDto.otherRace.nativeHawaiin\"}})],1),_c('v-col',{attrs:{\"cols\":\"4\"}},[_c('v-checkbox',{attrs:{\"label\":\"Guamanian or Chamorro\"},model:{value:(_vm.mothersWorksheetDto.otherRace.guamanianOrChamorro),callback:function ($$v) {_vm.$set(_vm.mothersWorksheetDto.otherRace, \"guamanianOrChamorro\", $$v)},expression:\"mothersWorksheetDto.otherRace.guamanianOrChamorro\"}})],1),_c('v-col',{attrs:{\"cols\":\"4\"}},[_c('v-checkbox',{attrs:{\"label\":\"Samoan\"},model:{value:(_vm.mothersWorksheetDto.otherRace.samoan),callback:function ($$v) {_vm.$set(_vm.mothersWorksheetDto.otherRace, \"samoan\", $$v)},expression:\"mothersWorksheetDto.otherRace.samoan\"}})],1),_c('v-col',{attrs:{\"cols\":\"4\"}},[_c('v-checkbox',{attrs:{\"label\":\"Other Pacific Islander\"},model:{value:(_vm.mothersWorksheetDto.otherRace.otherPacificIslander),callback:function ($$v) {_vm.$set(_vm.mothersWorksheetDto.otherRace, 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$$v)},expression:\"mothersWorksheetDto.otherRace.otherPacificIslanderText2\"}}):_vm._e()],1),_c('v-col',{attrs:{\"cols\":\"4\"}},[_c('v-checkbox',{attrs:{\"label\":\"Other\"},model:{value:(_vm.mothersWorksheetDto.otherRace.other),callback:function ($$v) {_vm.$set(_vm.mothersWorksheetDto.otherRace, \"other\", $$v)},expression:\"mothersWorksheetDto.otherRace.other\"}}),(_vm.mothersWorksheetDto.otherRace.other)?_c('v-text-field',{attrs:{\"label\":\"Other\",\"required\":\"\",\"rules\":_vm.requiredRule},model:{value:(_vm.mothersWorksheetDto.otherRace.otherText),callback:function ($$v) {_vm.$set(_vm.mothersWorksheetDto.otherRace, \"otherText\", $$v)},expression:\"mothersWorksheetDto.otherRace.otherText\"}}):_vm._e(),(_vm.mothersWorksheetDto.otherRace.other)?_c('v-text-field',{attrs:{\"label\":\"Other 2\"},model:{value:(_vm.mothersWorksheetDto.otherRace.otherText2),callback:function ($$v) {_vm.$set(_vm.mothersWorksheetDto.otherRace, \"otherText2\", $$v)},expression:\"mothersWorksheetDto.otherRace.otherText2\"}}):_vm._e()],1),_c('v-col',{attrs:{\"cols\":\"4\"}},[_c('v-checkbox',{attrs:{\"label\":\"Unknown\"},model:{value:(_vm.mothersWorksheetDto.otherRace.unknown),callback:function ($$v) {_vm.$set(_vm.mothersWorksheetDto.otherRace, \"unknown\", $$v)},expression:\"mothersWorksheetDto.otherRace.unknown\"}})],1),_c('v-col',{attrs:{\"cols\":\"4\"}},[_c('v-checkbox',{attrs:{\"label\":\"Refuse\"},model:{value:(_vm.mothersWorksheetDto.otherRace.decline),callback:function ($$v) {_vm.$set(_vm.mothersWorksheetDto.otherRace, \"decline\", $$v)},expression:\"mothersWorksheetDto.otherRace.decline\"}})],1),_c('v-col',{attrs:{\"cols\":\"4\"}},[_c('v-checkbox',{attrs:{\"label\":\"Not Obtainable\"},model:{value:(_vm.mothersWorksheetDto.otherRace.notObtainable),callback:function ($$v) {_vm.$set(_vm.mothersWorksheetDto.otherRace, \"notObtainable\", $$v)},expression:\"mothersWorksheetDto.otherRace.notObtainable\"}})],1)],1),_c('v-row',{attrs:{\"align\":\"center\"}},[_c('v-col',{attrs:{\"cols\":\"6\"}},[_c('b',[_vm._v(\"22. Mother's Height?\"),_c('b',{staticStyle:{\"color\":\"red\"}},[_vm._v(\"*\")])])]),_c('v-col',{attrs:{\"cols\":\"3\"}},[_c('v-text-field',{attrs:{\"type\":\"number\",\"required\":\"\",\"rules\":_vm.requiredFeetRule,\"label\":\"Feet\"},model:{value:(_vm.mothersWorksheetDto.heightFeet),callback:function ($$v) {_vm.$set(_vm.mothersWorksheetDto, \"heightFeet\", $$v)},expression:\"mothersWorksheetDto.heightFeet\"}})],1),_c('v-col',{attrs:{\"cols\":\"3\"}},[_c('v-text-field',{attrs:{\"type\":\"number\",\"required\":\"\",\"rules\":_vm.requiredInchRule,\"label\":\"Inches\"},model:{value:(_vm.mothersWorksheetDto.heightInches),callback:function ($$v) {_vm.$set(_vm.mothersWorksheetDto, \"heightInches\", $$v)},expression:\"mothersWorksheetDto.heightInches\"}})],1)],1),_c('v-row',{attrs:{\"align\":\"center\"}},[_c('v-col',{attrs:{\"cols\":\"9\"}},[_c('b',[_vm._v(\"23. Mother’s Pre-pregnancy Weight\"),_c('b',{staticStyle:{\"color\":\"red\"}},[_vm._v(\"*\")])]),_vm._v(\" - mother’s weight immediately before she became pregnant?\\n \")]),_c('v-col',{attrs:{\"cols\":\"3\"}},[_c('v-text-field',{attrs:{\"required\":\"\",\"rules\":_vm.requiredRule,\"type\":\"number\",\"label\":\"Pounds\"},model:{value:(_vm.mothersWorksheetDto.weight),callback:function ($$v) {_vm.$set(_vm.mothersWorksheetDto, \"weight\", $$v)},expression:\"mothersWorksheetDto.weight\"}})],1)],1),_c('v-row',{attrs:{\"align\":\"center\"}},[_c('v-col',{attrs:{\"cols\":\"9\"}},[_c('b',[_vm._v(\"24. Did mother get WIC (Women, Infants, and Children) food for herself because she was pregnant with this child?\"),_c('b',{staticStyle:{\"color\":\"red\"}},[_vm._v(\"*\")])])]),_c('v-col',{attrs:{\"cols\":\"3\"}},[_c('v-select',{attrs:{\"items\":_vm.yesNo,\"item-text\":\"description\",\"item-value\":\"id\",\"required\":\"\",\"rules\":_vm.requiredDateRule},model:{value:(_vm.mothersWorksheetDto.wicYN),callback:function ($$v) {_vm.$set(_vm.mothersWorksheetDto, \"wicYN\", $$v)},expression:\"mothersWorksheetDto.wicYN\"}})],1)],1),_c('v-row',[_c('v-col',{attrs:{\"cols\":\"12\"}},[_c('b',[_vm._v(\"25. Cigarette Smoking Before and During Pregnancy\"),_c('b',{staticStyle:{\"color\":\"red\"}},[_vm._v(\"*\")]),_vm._v(\" -\")]),_vm._v(\"\\n How many cigarettes OR packs of cigarettes did the MOTHER smoke on an average \"),_c('u',[_vm._v(\"day\")]),_vm._v(\" during each of the following time periods?\\n If the Mother never smoked, select the box and skip to question 26.\\n \")])],1),_c('v-row',[_c('v-col',{attrs:{\"cols\":\"12\"}},[_c('v-checkbox',{attrs:{\"label\":\"Never Smoked (Skip to Question 26)\"},on:{\"click\":function($event){return _vm.toggleZeros()}},model:{value:(_vm.mothersWorksheetDto.neverSmoked),callback:function ($$v) {_vm.$set(_vm.mothersWorksheetDto, \"neverSmoked\", $$v)},expression:\"mothersWorksheetDto.neverSmoked\"}})],1)],1),_c('v-row',{attrs:{\"align\":\"center\"}},[_c('v-col',{attrs:{\"cols\":\"5\"}},[_vm._v(\"\\n Three months \"),_c('b',{staticStyle:{\"color\":\"red\"}},[_vm._v(\"BEFORE\")]),_vm._v(\" pregnancy\\n \")]),_c('v-col',{attrs:{\"cols\":\"3\"}},[_c('v-text-field',{attrs:{\"label\":\"Cigarettes/Day\"},model:{value:(_vm.mothersWorksheetDto.beforePregnancyCigs),callback:function ($$v) {_vm.$set(_vm.mothersWorksheetDto, \"beforePregnancyCigs\", $$v)},expression:\"mothersWorksheetDto.beforePregnancyCigs\"}})],1),_c('v-col',{attrs:{\"cols\":\"1\"}},[_vm._v(\"\\n OR\\n \")]),_c('v-col',{attrs:{\"cols\":\"3\"}},[_c('v-text-field',{attrs:{\"label\":\"Packs/Day\"},model:{value:(_vm.mothersWorksheetDto.beforePregnancyPacks),callback:function ($$v) {_vm.$set(_vm.mothersWorksheetDto, \"beforePregnancyPacks\", $$v)},expression:\"mothersWorksheetDto.beforePregnancyPacks\"}})],1)],1),_c('v-divider'),_c('v-row',{attrs:{\"align\":\"center\"}},[_c('v-col',{attrs:{\"cols\":\"5\"}},[_c('b',[_vm._v(\"First three months\")]),_vm._v(\" of pregnancy\\n \")]),_c('v-col',{attrs:{\"cols\":\"3\"}},[_c('v-text-field',{attrs:{\"label\":\"Cigarettes/Day\"},model:{value:(_vm.mothersWorksheetDto.firstThreePregnancyCigs),callback:function ($$v) {_vm.$set(_vm.mothersWorksheetDto, \"firstThreePregnancyCigs\", $$v)},expression:\"mothersWorksheetDto.firstThreePregnancyCigs\"}})],1),_c('v-col',{attrs:{\"cols\":\"1\"}},[_vm._v(\"\\n OR\\n \")]),_c('v-col',{attrs:{\"cols\":\"3\"}},[_c('v-text-field',{attrs:{\"label\":\"Packs/Day\"},model:{value:(_vm.mothersWorksheetDto.firstThreePregnancyPacks),callback:function ($$v) {_vm.$set(_vm.mothersWorksheetDto, \"firstThreePregnancyPacks\", $$v)},expression:\"mothersWorksheetDto.firstThreePregnancyPacks\"}})],1)],1),_c('v-divider'),_c('v-row',{attrs:{\"align\":\"center\"}},[_c('v-col',{attrs:{\"cols\":\"5\"}},[_c('b',[_vm._v(\"Second three months\")]),_vm._v(\" of pregnancy\\n \")]),_c('v-col',{attrs:{\"cols\":\"3\"}},[_c('v-text-field',{attrs:{\"label\":\"Cigarettes/Day\"},model:{value:(_vm.mothersWorksheetDto.secondThreePregnancyCigs),callback:function ($$v) {_vm.$set(_vm.mothersWorksheetDto, \"secondThreePregnancyCigs\", $$v)},expression:\"mothersWorksheetDto.secondThreePregnancyCigs\"}})],1),_c('v-col',{attrs:{\"cols\":\"1\"}},[_vm._v(\"\\n OR\\n \")]),_c('v-col',{attrs:{\"cols\":\"3\"}},[_c('v-text-field',{attrs:{\"label\":\"Packs/Day\"},model:{value:(_vm.mothersWorksheetDto.secondThreePregnancyPacks),callback:function ($$v) {_vm.$set(_vm.mothersWorksheetDto, \"secondThreePregnancyPacks\", $$v)},expression:\"mothersWorksheetDto.secondThreePregnancyPacks\"}})],1)],1),_c('v-divider'),_c('v-row',{attrs:{\"align\":\"center\"}},[_c('v-col',{attrs:{\"cols\":\"5\"}},[_c('b',[_vm._v(\"Last three months\")]),_vm._v(\" of pregnancy\\n \")]),_c('v-col',{attrs:{\"cols\":\"3\"}},[_c('v-text-field',{attrs:{\"label\":\"Cigarettes/Day\"},model:{value:(_vm.mothersWorksheetDto.finalThreePregnancyCigs),callback:function ($$v) {_vm.$set(_vm.mothersWorksheetDto, \"finalThreePregnancyCigs\", $$v)},expression:\"mothersWorksheetDto.finalThreePregnancyCigs\"}})],1),_c('v-col',{attrs:{\"cols\":\"1\"}},[_vm._v(\"\\n OR\\n \")]),_c('v-col',{attrs:{\"cols\":\"3\"}},[_c('v-text-field',{attrs:{\"label\":\"Packs/Day\"},model:{value:(_vm.mothersWorksheetDto.finalThreePregnancyPacks),callback:function ($$v) {_vm.$set(_vm.mothersWorksheetDto, \"finalThreePregnancyPacks\", $$v)},expression:\"mothersWorksheetDto.finalThreePregnancyPacks\"}})],1)],1),_c('v-divider'),_c('v-row',{attrs:{\"align\":\"center\"}},[_c('v-col',{attrs:{\"cols\":\"12\"}},[_c('b',[_vm._v(\"26. Month Prenatal Care Began\"),_c('b',{staticStyle:{\"color\":\"red\"}},[_vm._v(\"*\")]),_vm._v(\" -\")])]),_c('v-col',{attrs:{\"cols\":\"12\"}},[_vm._v(\"\\n Enter the month of pregnancy when the mother began going to the doctor for prenatal\\n care. \"),_c('u',[_vm._v(\"Please only enter a value between 01 through 10.\")]),_vm._v(\" If the mother did not receive prenatal care, please enter “NONE” in the space provided\\n \")]),_c('v-col',{attrs:{\"cols\":\"12\"}},[_c('v-text-field',{attrs:{\"label\":\"Month Prenatal Care Began\",\"required\":\"\",\"rules\":_vm.prenatalCareRule},model:{value:(_vm.mothersWorksheetDto.prenatalCare),callback:function ($$v) {_vm.$set(_vm.mothersWorksheetDto, \"prenatalCare\", $$v)},expression:\"mothersWorksheetDto.prenatalCare\"}})],1),_c('v-col',{attrs:{\"cols\":\"12\"}},[_vm._v(\"\\n (Example: 1 = Prenatal care began the \"),_c('b',[_vm._v(\"first month\")]),_vm._v(\" of pregnancy and 2 = Prenatal care began the second month of pregnancy.)\\n \")])],1)],1)],1)],1)],1)],1),(!_vm.isSubmitted && !_vm.isSaved && !_vm.mothersWorksheetDto.completed)?[_c('v-row',[(_vm.showErrors() && !_vm.isSaved && !_vm.isSubmitted)?_c('v-col',{attrs:{\"cols\":\"12\"}},[_c('label',[_vm._v(\"Please correct the following errors:\")])]):_vm._e(),_c('v-col',{attrs:{\"cols\":\"12\"}},[_c('ul',_vm._l((_vm.errors),function(error){return _c('li',{key:error,staticClass:\"red--text\"},[_vm._v(_vm._s(error))])}),0)])],1),_c('v-row',{attrs:{\"align\":\"center\",\"justify\":\"center\"}},[_c('v-col',{attrs:{\"cols\":\"12\"}},[_c('u',{staticStyle:{\"color\":\"red\",\"font-style\":\"italic\"}},[_vm._v(\"Before submitting, please make sure ALL applicable questions have been answered.\\n If there are blank items, they may have a negative impact on the filing of the birth certificate.\")]),_c('br'),_c('br'),_vm._v(\"\\n By clicking SUBMIT, I certify the information provided for this certificate is correct to the best of my knowledge and belief.\"),_c('br'),_vm._v(\"\\n I also acknowledge that submitting this form constitutes an electronic signature and will be considered as a handwritten signature for all purposes and shall have\\n the same force and effect as a handwritten signature.\\n \")])],1)]:_vm._e(),(!_vm.mothersWorksheetDto.completed)?_c('v-row',[(_vm.isSubmitted)?_c('v-col',{attrs:{\"cols\":\"12\"}},[_c('b',[_vm._v(\"Worksheet has been submitted! The reference number for this worksheet is \"),_c('u',[_vm._v(_vm._s(_vm.mothersWorksheetDto.portalMothersWorksheetId))]),_vm._v(\".\")])]):_vm._e(),(_vm.isSaved && !_vm.isSubmitted)?_c('v-col',{attrs:{\"cols\":\"12\"}},[_c('b',{staticStyle:{\"background-color\":\"yellow\"}},[_vm._v(\"The worksheet has been saved. Go to your inbox to continue working on worksheet \"),_c('u',[_vm._v(_vm._s(_vm.mothersWorksheetDto.portalMothersWorksheetId))]),_vm._v(\".\")])]):_vm._e(),(!_vm.isSaved && !_vm.isSubmitted)?_c('v-col',{attrs:{\"cols\":\"6\"}},[_c('v-btn',{attrs:{\"color\":\"secondary\",\"disabled\":_vm.isSubmitted || _vm.isLoading},on:{\"click\":function($event){return _vm.sendMothersWorksheet(true)}}},[_vm._v(\"\\n SUBMIT\\n \")])],1):_vm._e(),(!_vm.isSaved && !_vm.isSubmitted)?_c('v-col',{attrs:{\"cols\":\"6\"}},[_c('v-btn',{attrs:{\"color\":\"secondary\",\"disabled\":_vm.isLoading || _vm.isSubmitted},on:{\"click\":function($event){return _vm.sendMothersWorksheet(false)}}},[_vm._v(\"\\n SAVE UNFINISHED\\n \")])],1):_vm._e()],1):_c('v-row',[_c('v-col')],1)],2)}\nvar staticRenderFns = []\n\nexport { render, staticRenderFns }","var render = function () {var _vm=this;var _h=_vm.$createElement;var _c=_vm._self._c||_h;return _c('div',[_c('v-container',[_c('v-layout',[_c('v-row',[_c('v-col',{attrs:{\"cols\":\"3\"}},[_c('v-text-field',{attrs:{\"label\":\"First Name\",\"required\":this.isRequired,\"rules\":_vm.requiredRule},model:{value:(_vm.nameDto.firstName),callback:function ($$v) {_vm.$set(_vm.nameDto, \"firstName\", $$v)},expression:\"nameDto.firstName\"}})],1),_c('v-col',{attrs:{\"cols\":\"3\"}},[_c('v-text-field',{attrs:{\"label\":\"Middle Name\",\"required\":this.isRequired,\"rules\":_vm.requiredRule},model:{value:(_vm.nameDto.middleName),callback:function ($$v) {_vm.$set(_vm.nameDto, \"middleName\", $$v)},expression:\"nameDto.middleName\"}})],1),_c('v-col',{attrs:{\"cols\":\"3\"}},[_c('v-text-field',{attrs:{\"label\":\"Last Name\",\"required\":this.isRequired,\"rules\":_vm.requiredRule},model:{value:(_vm.nameDto.lastName),callback:function ($$v) {_vm.$set(_vm.nameDto, \"lastName\", $$v)},expression:\"nameDto.lastName\"}})],1),_c('v-col',{attrs:{\"cols\":\"1\"}},[_c('v-tooltip',{attrs:{\"bottom\":\"\"},scopedSlots:_vm._u([{key:\"activator\",fn:function(ref){\nvar on = ref.on;\nvar attrs = ref.attrs;\nreturn [_c('v-icon',_vm._g(_vm._b({},'v-icon',attrs,false),on),[_vm._v(\"mdi-information-outline\")])]}}])},[_c('span',{staticStyle:{\"color\":\"white\"}},[_vm._v(\"Please enter the last name as you want it to be on the Birth Certificate. Dashes and spaces are allowed.\")])])],1),_c('v-col',{attrs:{\"cols\":\"2\"}},[_c('v-select',{ref:\"suffixRef\",attrs:{\"items\":_vm.suffixes,\"item-text\":\"description\",\"item-value\":\"id\",\"label\":\"Suffix\",\"clearable\":\"\"},model:{value:(_vm.nameDto.suffix),callback:function ($$v) {_vm.$set(_vm.nameDto, \"suffix\", $$v)},expression:\"nameDto.suffix\"}})],1)],1)],1)],1)],1)}\nvar staticRenderFns = []\n\nexport { render, staticRenderFns }","\r\n
\r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n mdi-information-outline\r\n \r\n Please enter the last name as you want it to be on the Birth Certificate. Dashes and spaces are allowed.\r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n
\r\n \r\n \r\n \r\n The information you provide below will be used to complete your child’s birth certificate.\r\n The birth certificate is a document that will be used for legal purposes to prove your child’s age, citizenship, and parentage.\r\n Your child throughout his or her life will use the information from this document.\r\n Please take care to answer each question as accurately as possible.\r\n If you have a problem with some of the questions, please ask the birth certificate clerk in the hospital for assistance. \r\n\r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n
\r\n SUBMITTED\r\n
\r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n * Denotes a required field.\r\n \r\n \r\n \r\n 1. Child's Name* - \r\n This should be the name that child will use throughout life.\r\n The child’s given first and middle names may be changed within one year of the date of birth.\r\n The last name(s) entered here may only be changed by court order or by an Affidavit Acknowledging paternity.\r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n\r\n \r\n \r\n \r\n 2. Mother's Current Legal Name* -\r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n List additional surnames if applicable. Note - some countries require surnames of both parents for dual citizenship -\r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n 3. Mother's Date of Birth* -\r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n 4. Mother's Name Before First Marriage (Maiden Name)* -\r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n 5. Mother's Place of Birth* - Select the U.S. State, U.S. Territory, or Foreign Country:\r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n 6. Mother's Residence, Address, and Contact Information* - \r\n This should be the place at which the mother has set up housekeeping.\r\n It is not to be a temporary residence used during a visit or vacation.\r\n Residence during a tour of military duty or during attendance at college should be entered.\r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n Is this residence inside the city limits?*\r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n Mother's Primary Telephone/Cellular Phone Number* - \r\n \r\n \r\n \r\n \r\n \r\n \r\n Mother's Email Address* -\r\n \r\n \r\n \r\n \r\n \r\n \r\n\r\n \r\n \r\n \r\n 7. Mother's Marital Status* - VERY IMPORTANT - ITEMS 7 AND 8 ESTABLISH PATERNITY FOR THE CHILD.\r\n \r\n \r\n a. Was the Mother married to anyone within the 300 days prior to birth?\r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n b. If YES, is the spouse the father/parent of the child?\r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n 8. Paternity Acknowledgement - Complete if the mother was not married to the child’s natural/biological father.\r\n \r\n \r\n a. Has the natural/biological father signed an Affidavit Acknowledging Paternity?\r\n \r\n \r\n \r\n \r\n \r\n \r\n b. If the mother was married, has her husband/spouse signed an affidavit denying paternity?\r\n \r\n \r\n \r\n \r\n \r\n \r\n For more information about paternity acknowledgement:\r\n Affidavit Info\r\n \r\n \r\n \r\n \r\n 9. Father/Parent's Current Legal Name - If the mother was unmarried throughout her pregnancy, a father may only be\r\n named if an Affidavit Acknowledging Paternity is signed. If the mother was married at any time during the pregnancy\r\n (300 days prior to birth), the name of the spouse must be entered as the father/parent unless the natural/biological father\r\n signs an Affidavit Acknowledging Paternity. If the spouse does not sign an affidavit denying paternity, contact Vital\r\n Statistics Services immediately for guidance on completing the filing. The affidavit forms may be obtained from the birth\r\n certificate clerk.\r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n List additional surnames if applicable. Note - some countries require surnames of both parents for dual citizenship -\r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n 10. Father/Parent's Date of Birth - \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n 11. Father/Parent's Place of Birth - Select the U.S. State, U.S. Territory, or Foreign Country:\r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n\r\n \r\n \r\n \r\n 12. Mother's Mailing Address and Contact Information - If same as Residence Address, skip to question 13.\r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n 13. Information Released to Obtain a Social Security Number?*\r\n Check \"YES\" if the parents wish to have information released from this form to the Social Security Administration to assign a Social Security number to this child.\r\n \r\n \r\n A Social Security card for the child will be sent directly to the Mother’s Mailing Address\r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n 14. Information Released to Wyoming Department of Health Public Health Nurse County Services?\r\n \r\n \r\n A Public Health Nurse Representative will contact mothers to provide information regarding services available in her community.\r\n Check “NO” if the mother does NOT want to obtain information regarding services provided by Public Health Nursing in her community.\r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n 15. Parents' Social Security Numbers* -\r\n \r\n \r\n Furnishing the parents’ Social Security Numbers is required by Federal Law, 42 USC 405(c) (section205(c) of the Social Security Act).\r\n The numbers will be made available to the Wyoming Department of Family Services to assist with child support enforcement activities and to the Internal Revenue Service for the purpose of determining Earned Income Tax Credit compliance.\r\n \r\n \r\n \r\n \r\n Mother's SSN\r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n Father/Parent's SSN\r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n The following information is needed to compile statistics to be used for planning and evaluating health programs for expectant mothers and newborn infants. It will not be included on certified copies of the birth certificate.\r\n \r\n \r\n \r\n \r\n 16. Mother's Education* - \r\n Select the item that best describes the highest degree or level of school completed at the time of delivery.\r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n 17. Mother's Hispanic Origin* - \r\n Select the item that best describes whether the mother is Spanish/ Hispanic/ Latina. Select “NO” if the mother is not Spanish/ Hispanic/ Latina.\r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n 18. Mother's Race* - \r\n Check one or more races to indicate what the mother considers herself to be.\r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n 19. Father/Parent's Education - \r\n Select the item that best describes the highest degree or level of school completed at the time of delivery\r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n 20. Father/Parent's Hispanic Origin - \r\n Select the item that best describes whether the father/parent is Spanish/ Hispanic/ Latino. Select “NO” if the father/parent is not Spanish/ Hispanic/ Latino.\r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n 21. Father/Parent's Race - \r\n Check one or more races to indicate what the father/other parent considers himself/themselves to be.\r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n\r\n \r\n \r\n \r\n 22. Mother's Height?*\r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n 23. Mother’s Pre-pregnancy Weight* - mother’s weight immediately before she became pregnant?\r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n 24. Did mother get WIC (Women, Infants, and Children) food for herself because she was pregnant with this child?*\r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n 25. Cigarette Smoking Before and During Pregnancy* -\r\n How many cigarettes OR packs of cigarettes did the MOTHER smoke on an average day during each of the following time periods?\r\n If the Mother never smoked, select the box and skip to question 26.\r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n Three months BEFORE pregnancy\r\n \r\n \r\n \r\n \r\n \r\n \r\n OR\r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n First three months of pregnancy\r\n \r\n \r\n \r\n \r\n \r\n \r\n OR\r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n Second three months of pregnancy\r\n \r\n \r\n \r\n \r\n \r\n \r\n OR\r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n Last three months of pregnancy\r\n \r\n \r\n \r\n \r\n \r\n \r\n OR\r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n 26. Month Prenatal Care Began* -\r\n \r\n \r\n Enter the month of pregnancy when the mother began going to the doctor for prenatal\r\n care. Please only enter a value between 01 through 10. If the mother did not receive prenatal care, please enter “NONE” in the space provided\r\n \r\n \r\n \r\n \r\n \r\n (Example: 1 = Prenatal care began the first month of pregnancy and 2 = Prenatal care began the second month of pregnancy.)\r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n
\r\n
{{error}}
\r\n
\r\n \r\n \r\n \r\n \r\n Before submitting, please make sure ALL applicable questions have been answered.\r\n If there are blank items, they may have a negative impact on the filing of the birth certificate.
\r\n By clicking SUBMIT, I certify the information provided for this certificate is correct to the best of my knowledge and belief. \r\n I also acknowledge that submitting this form constitutes an electronic signature and will be considered as a handwritten signature for all purposes and shall have\r\n the same force and effect as a handwritten signature.\r\n \r\n \r\n \r\n \r\n \r\n Worksheet has been submitted! The reference number for this worksheet is {{ mothersWorksheetDto.portalMothersWorksheetId }}.\r\n \r\n \r\n The worksheet has been saved. Go to your inbox to continue working on worksheet {{ mothersWorksheetDto.portalMothersWorksheetId }}.\r\n \r\n \r\n \r\n SUBMIT\r\n \r\n \r\n \r\n \r\n SAVE UNFINISHED\r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n\r\n\r\n\r\n","import mod from \"-!../../node_modules/cache-loader/dist/cjs.js??ref--12-0!../../node_modules/thread-loader/dist/cjs.js!../../node_modules/babel-loader/lib/index.js!../../node_modules/cache-loader/dist/cjs.js??ref--0-0!../../node_modules/vue-loader/lib/index.js??vue-loader-options!./MothersWorksheet.vue?vue&type=script&lang=js&\"; export default mod; export * from \"-!../../node_modules/cache-loader/dist/cjs.js??ref--12-0!../../node_modules/thread-loader/dist/cjs.js!../../node_modules/babel-loader/lib/index.js!../../node_modules/cache-loader/dist/cjs.js??ref--0-0!../../node_modules/vue-loader/lib/index.js??vue-loader-options!./MothersWorksheet.vue?vue&type=script&lang=js&\"","import { render, staticRenderFns } from \"./MothersWorksheet.vue?vue&type=template&id=031caf93&scoped=true&\"\nimport script from \"./MothersWorksheet.vue?vue&type=script&lang=js&\"\nexport * from \"./MothersWorksheet.vue?vue&type=script&lang=js&\"\nimport style0 from \"./MothersWorksheet.vue?vue&type=style&index=0&id=031caf93&scoped=true&lang=css&\"\n\n\n/* normalize component */\nimport normalizer from \"!../../node_modules/vue-loader/lib/runtime/componentNormalizer.js\"\nvar component = normalizer(\n script,\n render,\n staticRenderFns,\n false,\n null,\n \"031caf93\",\n null\n \n)\n\nexport default component.exports\n\n/* vuetify-loader */\nimport installComponents from \"!../../node_modules/vuetify-loader/lib/runtime/installComponents.js\"\nimport { VBtn } from 'vuetify/lib/components/VBtn';\nimport { VCard } from 'vuetify/lib/components/VCard';\nimport { VCheckbox } from 'vuetify/lib/components/VCheckbox';\nimport { VCol } from 'vuetify/lib/components/VGrid';\nimport { VContainer } from 'vuetify/lib/components/VGrid';\nimport { VDivider } from 'vuetify/lib/components/VDivider';\nimport { VForm } from 'vuetify/lib/components/VForm';\nimport { VProgressCircular } from 'vuetify/lib/components/VProgressCircular';\nimport { VRow } from 'vuetify/lib/components/VGrid';\nimport { VSelect } from 'vuetify/lib/components/VSelect';\nimport { VTextField } from 'vuetify/lib/components/VTextField';\ninstallComponents(component, {VBtn,VCard,VCheckbox,VCol,VContainer,VDivider,VForm,VProgressCircular,VRow,VSelect,VTextField})\n","// Styles\nimport './VCheckbox.sass'\nimport '../../styles/components/_selection-controls.sass'\n\n// Components\nimport VIcon from '../VIcon'\nimport VInput from '../VInput'\n\n// Mixins\nimport Selectable from '../../mixins/selectable'\n\n/* @vue/component */\nexport default Selectable.extend({\n name: 'v-checkbox',\n\n props: {\n indeterminate: Boolean,\n indeterminateIcon: {\n type: String,\n default: '$checkboxIndeterminate',\n },\n offIcon: {\n type: String,\n default: '$checkboxOff',\n },\n onIcon: {\n type: String,\n default: '$checkboxOn',\n },\n },\n\n data () {\n return {\n inputIndeterminate: this.indeterminate,\n }\n },\n\n computed: {\n classes (): object {\n return {\n ...VInput.options.computed.classes.call(this),\n 'v-input--selection-controls': true,\n 'v-input--checkbox': true,\n 'v-input--indeterminate': this.inputIndeterminate,\n }\n },\n computedIcon (): string {\n if (this.inputIndeterminate) {\n return this.indeterminateIcon\n } else if (this.isActive) {\n return this.onIcon\n } else {\n return this.offIcon\n }\n },\n // Do not return undefined if disabled,\n // according to spec, should still show\n // a color when disabled and active\n validationState (): string | undefined {\n if (this.isDisabled && !this.inputIndeterminate) return undefined\n if (this.hasError && this.shouldValidate) return 'error'\n if (this.hasSuccess) return 'success'\n if (this.hasColor !== null) return this.computedColor\n return undefined\n },\n },\n\n watch: {\n indeterminate (val) {\n // https://github.com/vuetifyjs/vuetify/issues/8270\n this.$nextTick(() => (this.inputIndeterminate = val))\n },\n inputIndeterminate (val) {\n this.$emit('update:indeterminate', val)\n },\n isActive () {\n if (!this.indeterminate) return\n this.inputIndeterminate = false\n },\n },\n\n methods: {\n genCheckbox () {\n const { title, ...checkboxAttrs } = this.attrs$\n return this.$createElement('div', {\n staticClass: 'v-input--selection-controls__input',\n }, [\n this.$createElement(VIcon, this.setTextColor(this.validationState, {\n props: {\n dense: this.dense,\n dark: this.dark,\n light: this.light,\n },\n }), this.computedIcon),\n this.genInput('checkbox', {\n ...checkboxAttrs,\n 'aria-checked': this.inputIndeterminate\n ? 'mixed'\n : this.isActive.toString(),\n }),\n this.genRipple(this.setTextColor(this.rippleState)),\n ])\n },\n genDefaultSlot () {\n return [\n this.genCheckbox(),\n this.genLabel(),\n ]\n },\n },\n})\n","// Directives\nimport ripple from '../../directives/ripple'\n\n// Types\nimport Vue, { VNode, VNodeData, VNodeDirective } from 'vue'\n\nexport default Vue.extend({\n name: 'rippleable',\n\n directives: { ripple },\n\n props: {\n ripple: {\n type: [Boolean, Object],\n default: true,\n },\n },\n\n methods: {\n genRipple (data: VNodeData = {}): VNode | null {\n if (!this.ripple) return null\n\n data.staticClass = 'v-input--selection-controls__ripple'\n\n data.directives = data.directives || []\n data.directives.push({\n name: 'ripple',\n value: { center: true },\n } as VNodeDirective)\n\n return this.$createElement('div', data)\n },\n },\n})\n","// Components\nimport VInput from '../../components/VInput'\n\n// Mixins\nimport Rippleable from '../rippleable'\nimport Comparable from '../comparable'\n\n// Utilities\nimport mixins from '../../util/mixins'\n\nexport function prevent (e: Event) {\n e.preventDefault()\n}\n\n/* @vue/component */\nexport default mixins(\n VInput,\n Rippleable,\n Comparable\n).extend({\n name: 'selectable',\n\n model: {\n prop: 'inputValue',\n event: 'change',\n },\n\n props: {\n id: String,\n inputValue: null as any,\n falseValue: null as any,\n trueValue: null as any,\n multiple: {\n type: Boolean,\n default: null,\n },\n label: String,\n },\n\n data () {\n return {\n hasColor: this.inputValue,\n lazyValue: this.inputValue,\n }\n },\n\n computed: {\n computedColor (): string | undefined {\n if (!this.isActive) return undefined\n if (this.color) return this.color\n if (this.isDark && !this.appIsDark) return 'white'\n return 'primary'\n },\n isMultiple (): boolean {\n return this.multiple === true || (this.multiple === null && Array.isArray(this.internalValue))\n },\n isActive (): boolean {\n const value = this.value\n const input = this.internalValue\n\n if (this.isMultiple) {\n if (!Array.isArray(input)) return false\n\n return input.some(item => this.valueComparator(item, value))\n }\n\n if (this.trueValue === undefined || this.falseValue === undefined) {\n return value\n ? this.valueComparator(value, input)\n : Boolean(input)\n }\n\n return this.valueComparator(input, this.trueValue)\n },\n isDirty (): boolean {\n return this.isActive\n },\n rippleState (): string | undefined {\n return !this.isDisabled && !this.validationState\n ? undefined\n : this.validationState\n },\n },\n\n watch: {\n inputValue (val) {\n this.lazyValue = val\n this.hasColor = val\n },\n },\n\n methods: {\n genLabel () {\n const label = VInput.options.methods.genLabel.call(this)\n\n if (!label) return label\n\n label!.data!.on = {\n // Label shouldn't cause the input to focus\n click: prevent,\n }\n\n return label\n },\n genInput (type: string, attrs: object) {\n return this.$createElement('input', {\n attrs: Object.assign({\n 'aria-checked': this.isActive.toString(),\n disabled: this.isDisabled,\n id: this.computedId,\n role: type,\n type,\n }, attrs),\n domProps: {\n value: this.value,\n checked: this.isActive,\n },\n on: {\n blur: this.onBlur,\n change: this.onChange,\n focus: this.onFocus,\n keydown: this.onKeydown,\n click: prevent,\n },\n ref: 'input',\n })\n },\n onClick (e: Event) {\n this.onChange()\n this.$emit('click', e)\n },\n onChange () {\n if (!this.isInteractive) return\n\n const value = this.value\n let input = this.internalValue\n\n if (this.isMultiple) {\n if (!Array.isArray(input)) {\n input = []\n }\n\n const length = input.length\n\n input = input.filter((item: any) => !this.valueComparator(item, value))\n\n if (input.length === length) {\n input.push(value)\n }\n } else if (this.trueValue !== undefined && this.falseValue !== undefined) {\n input = this.valueComparator(input, this.trueValue) ? this.falseValue : this.trueValue\n } else if (value) {\n input = this.valueComparator(input, value) ? null : value\n } else {\n input = !input\n }\n\n this.validate(true, input)\n this.internalValue = input\n this.hasColor = input\n },\n onFocus (e: FocusEvent) {\n this.isFocused = true\n this.$emit('focus', e)\n },\n onBlur (e: FocusEvent) {\n this.isFocused = false\n this.$emit('blur', e)\n },\n /** @abstract */\n onKeydown (e: Event) {},\n },\n})\n"],"sourceRoot":""}