The supply request form is the one-page order form of the West Virginia Vital Registration Office, part of the West Virginia DHHR Bureau for Public Health. Hospitals, nursing homes, county clerks and similar facilities use it to request the birth, death and fetal death forms and reports they file with Vital Registration. On this page you can fill out the form online on FillingPDF and download or print the completed PDF; the form itself is published by the agency at dhhr.wv.gov, and it is returned by fax.
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What is Supply Request Form – West Virginia?
The Supply Request Form is the West Virginia Vital Registration Office form on which a facility checks off the vital records supplies it needs and faxes the request to the office. It is published under the West Virginia DHHR Bureau for Public Health, Health Statistics Center.
The form has two parts. The top asks for the facility name, facility address (city, state, ZIP), a contact person and a phone number. The second part is a checklist headed "Place a checkmark on the line next to the supply you need." The items listed are:
- Application for Certified Copies of Birth or Death Certificates
- NEW Physician's/Medical Examiner's Death Certificate (for deaths occurring Sept 1, 2017 forward)
- Electronic Birth Certificate Paper (used for both birth certificates and fetal death reports)
- Authorization for Final Disposition - Fetal Death
- Monthly Hospital Report of Birth, Death, and Fetal Death
- Report of Induced Termination of Pregnancy
- Birth Worksheets: Mother's Copy (Pink), Facility's Copy (Blue, Yellow, Green) and Addendum 1
The Health Statistics Center describes the form on its Forms page as the one for hospitals, nursing homes, county clerks and similar facilities to request supplies from Vital Registration. It does not order Declaration of Paternity Affidavits or Voluntary Denial of Paternity forms: the form refers those to the Bureau for Child Support Enforcement. It is also not the data request form that the Health Statistics Center requires from anyone requesting statistics.
Who needs to file Supply Request Form – West Virginia?
Facilities that file birth, death and related records with the West Virginia Vital Registration Office use this form when they need more of the forms and paper listed on it. The Health Statistics Center names hospitals, nursing homes and county clerks, and adds "etc.", so other facilities that work with Vital Registration may use it too.
A facility completes one form listing every supply it wants, with a contact person who can answer questions about the order.
Do not use this form for other needs:
- Declaration of Paternity Affidavits or Voluntary Denial of Paternity forms. The form tells you to contact the Bureau for Child Support Enforcement; it prints the fax number 304-558-4742, Attn: Paternity Forms.
- Statistics requests. The Health Statistics Center says anyone requesting statistics must fill out its separate data request form.
- Circuit Court summaries of adoption-related changes to birth certificates, which have their own form listed on the same agency page.
When to file Supply Request Form – West Virginia
Send the Supply Request Form whenever your facility needs any of the supplies listed on it. The form prints no due date or schedule, so the timing is set by your own supply on hand. Note that the Physician's/Medical Examiner's Death Certificate on the list is labeled "NEW" and is for deaths occurring September 1, 2017 forward. The form states no processing or delivery time, so contact the Vital Registration Office at (304) 558-2931 about when to expect your order.
How to fill out Supply Request Form – West Virginia
Enter the facility name and address
Write the Facility Name and the Facility Address, including city, state and ZIP code, in the fields at the top.
Add a contact person and phone
Enter the Contact Person who handles supplies at your facility and a Phone Number where that person can be reached.
Check the supplies you need
In the checklist headed "Place a checkmark on the line next to the supply you need," mark each item you want, from the certified copy application to the Birth Worksheets Addendum 1.
Select the correct death certificate item
Mark the NEW Physician's/Medical Examiner's Death Certificate only for deaths occurring Sept 1, 2017 forward, as the label says.
Skip paternity affidavit forms
Do not look for Declaration of Paternity Affidavit or Voluntary Denial of Paternity forms here; contact the Bureau for Child Support Enforcement, as the form directs.
Review and download the completed PDF
Check that the facility details and every checkmark are correct, then download or print the completed PDF from FillingPDF and fax it as described under How to submit.
How to submit Supply Request Form – West Virginia
The form is returned by fax. It says "Please Fax this Form to: (304) 558-8001," the fax number of the West Virginia Vital Registration Office. The office's telephone number, (304) 558-2931, is also printed on the form.
- Fax: send the completed, one-page form to (304) 558-8001. Before you send it, check that the facility name, address, contact person and phone number are filled in and that each supply you want has a checkmark.
- Paternity forms: do not use this fax number to order Declaration of Paternity Affidavits or Voluntary Denial of Paternity forms. Contact the Bureau for Child Support Enforcement, fax 304-558-4742, Attn: Paternity Forms.
The form names no mailing address, online portal or fee. FillingPDF lets you fill out and download the PDF; submission follows the fax channel above.
Common mistakes to avoid
- Leaving the checkmark line blank next to the supplies you need; the form asks for a checkmark on the line beside each supply.
- Faxing the form to a number other than (304) 558-8001, the fax number printed on it.
- Ordering Declaration of Paternity Affidavits or Voluntary Denial of Paternity forms on this form; the form refers those to the Bureau for Child Support Enforcement.
- Omitting the contact person or phone number, so Vital Registration has no one to call about the order.
- Checking the NEW Physician's/Medical Examiner's Death Certificate for deaths before September 1, 2017; the item is labeled for deaths occurring Sept 1, 2017 forward.
- Using this form to ask for statistics; the Health Statistics Center requires its separate data request form for that.
Frequently asked questions
What is the supply request form for West Virginia Vital Registration?
It is the form on which a facility checks off the vital records supplies it needs, such as birth and death certificate applications, Electronic Birth Certificate Paper and hospital reports, and faxes the request to the West Virginia Vital Registration Office.
Who can use the Vital Registration supply request form?
The Health Statistics Center says it is for hospitals, nursing homes, county clerks, etc. to request supplies from Vital Registration. Each facility lists its name, address, contact person and phone number on the form.
Where do I send the supply request form?
Fax it to (304) 558-8001, the number printed on the form. The form also lists the office telephone number, (304) 558-2931, and names no mailing address or online submission method.
Can I order paternity affidavit forms with this form?
No. The form says that Declaration of Paternity Affidavits and Voluntary Denial of Paternity forms are obtained by contacting the Bureau for Child Support Enforcement, fax 304-558-4742, Attn: Paternity Forms.
What supplies can I request on the form?
The checklist includes the Application for Certified Copies of Birth or Death Certificates, the NEW death certificate, Electronic Birth Certificate Paper, fetal death disposition authorization, the monthly hospital report, the induced termination report and birth worksheets.
Can I fill out the supply request form online?
You can fill out the PDF online on FillingPDF and download or print it. FillingPDF does not send the request to West Virginia: you fax the completed form to Vital Registration yourself.
Is there a fee or deadline for the supply request form?
The form prints no fee and no due date. You send it when you need supplies; ask the Vital Registration Office at (304) 558-2931 about any cost or delivery time for your order.
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