Reg-26, FETAL DEATH CERTIFICATE - Government of New Jersey
REG-26JUL 18New Jersey Department of HealthCERTIFICATE OF FETAL DEATHSTATE FILE NO.1. NAME OF FETUS (First, Middle, Last) (OPTIONAL) FORMTEXT ?????2a. DATE OF DELIVERY (Mo/Day/Yr) FORMTEXT ?????2b. TIME (24 Hour) FORMTEXT ?????3. SEX FORMCHECKBOX MALE FORMCHECKBOX FEMALE FORMCHECKBOX UNKNOWN/UNDETERMINED4a. THIS DELIVERY FORMCHECKBOX SINGLE FORMCHECKBOX TWIN FORMCHECKBOX OTHER FORMTEXT ________(Specify)4b. IF NOT SINGLE DELIVERY, THIS FETUS DELIVERED FORMCHECKBOX 1st FORMCHECKBOX 2nd FORMCHECKBOX OTHER FORMTEXT ________(Specify)5a. PLACE OF DELIVERY1 FORMCHECKBOX HOSPITAL3 FORMCHECKBOX CLINIC/DOCTOR’S OFFICE5 FORMCHECKBOX OTHER (Specify): FORMTEXT ?????2 FORMCHECKBOX FREESTANDING BIRTHING CENTER4 FORMCHECKBOX HOME DELIVERY-Planned to deliver at home? FORMCHECKBOX Yes FORMCHECKBOX No5b. NAME OF FACILITY (If not institution, give street address) FORMTEXT ?????5c. FACILITY ID (NPI) FORMTEXT ?????5d. CITY, TOWN OR LOCATION OF DELIVERY FORMTEXT ?????5e. COUNTY OF DELIVERY FORMTEXT ?????5f. ZIP CODE OF DELIVERY FORMTEXT ?????6a. MOTHER’S CURRENT LEGAL NAME (First, Middle, Last, Suffix) FORMTEXT ?????6b. DATE OF BIRTH (Mo/Day/Yr) FORMTEXT ?????6c. MOTHER’S NAME PRIOR TO FIRST MARRIAGE (List name given at birth or on birth certificate/Maiden name)(First, Middle, Last, Suffix) FORMTEXT ?????6d. BIRTHPLACE (State, Territory or Foreign Country) FORMTEXT ?????7a. RESIDENCE OF MOTHER - STATE FORMTEXT ?????7b. COUNTY FORMTEXT ?????7c. CITY OR TOWN FORMTEXT ?????7d. STREET AND NUMBER FORMTEXT ?????7e. APT NO. FORMTEXT ?????7f. ZIP CODE (or Mother’s Mailing Address, if different from 7d) FORMTEXT ?????7g. INSIDE CITY LIMITS FORMCHECKBOX YES FORMCHECKBOX NO8a. FATHER’S CURRENT LEGAL NAME (First, Middle, Last, Suffix) FORMTEXT ?????8b. DATE OF BIRTH (Mo/Day/Yr) FORMTEXT ?????8c. BIRTHPLACE (State, Territory or Foreign Country) FORMTEXT ?????9a. NAME OF INFORMANT FORMTEXT ?????9b. RELATIONSHIP TO FETUS FORMTEXT ?????10. CAUSES/CONDITIONS CONTRIBUTING TO FETAL DEATH10a. INITIATING CAUSE/CONDITION (Among the choices below, select the ONE which most likely began the sequence of events resulting in the death of the fetus)10b. OTHER SIGNIFICANT CAUSES OR CONDITIONS(Select or specify all other conditions contributing to death in item 10b)MATERNAL CONDITIONS/DISEASES (Specify):MATERNAL CONDITIONS/DISEASES (Specify): FORMTEXT ????? FORMTEXT ?????COMPLICATIONS OF PLACENTA, CORD OR MEMBRANES: FORMCHECKBOX RUPTURE OF MEMBRANES PRIOR TO ONSET OF LABOR FORMCHECKBOX ABRUPTIO PLACENTA FORMCHECKBOX PLACENTAL INSUFFICIENCY FORMCHECKBOX PROLAPSED CORD FORMCHECKBOX CHORIOAMNIONITISCOMPLICATIONS OF PLACENTA, CORD OR MEMBRANES: FORMCHECKBOX RUPTURE OF MEMBRANES PRIOR TO ONSET OF LABOR FORMCHECKBOX ABRUPTIO PLACENTA FORMCHECKBOX PLACENTAL INSUFFICIENCY FORMCHECKBOX PROLAPSED CORD FORMCHECKBOX CHORIOAMNIONITIS FORMCHECKBOX OTHER (Specify): FORMTEXT ????? FORMCHECKBOX OTHER (Specify): FORMTEXT ?????OTHER OBSTETRICAL OR PREGNANCY COMPLICATIONS (Specify):OTHER OBSTETRICAL OR PREGNANCY COMPLICATIONS (Specify): FORMTEXT ????? FORMTEXT ?????FETAL ANOMALY (Specify): FORMTEXT ?????FETAL ANOMALY (Specify): FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????FETAL INJURY (Specify): FORMTEXT ?????FETAL INJURY (Specify): FORMTEXT ?????FETAL INFECTION (Specify): FORMTEXT ?????FETAL INFECTION (Specify): FORMTEXT ?????OTHER FETAL CONDITIONS/DISORDERS (Specify):OTHER FETAL CONDITIONS/DISORDERS (Specify): FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX UNKNOWN FORMCHECKBOX UNKNOWN10c. WEIGHT OF FETUS (grams preferred, specify unit)/oz FORMTEXT ????? FORMCHECKBOX grams FORMCHECKBOX lb/oz10d. OBSTRETRIC ESTIMATE OF GESTATION AT DELIVERY FORMTEXT ????? (completed weeks)10e. ESTIMATED TIME OF FETAL DEATH FORMCHECKBOX Dead at time of first assessment, no labor ongoing FORMCHECKBOX Dead at time of first assessment, labor ongoing FORMCHECKBOX Died during labor, after first assessment FORMCHECKBOX UNKNOWN TIME OF FETAL DEATH10f. WAS AN AUTOPSY PERFORMED? FORMCHECKBOX YES FORMCHECKBOX NO FORMCHECKBOX PLANNED10g. WAS A HISTOLOGICAL PLACENTAL EXAMINATION PERFORMED? FORMCHECKBOX YES FORMCHECKBOX NO FORMCHECKBOX PLANNED10h. WERE AUTOPSY OR HISTOLOGICAL PLACENTAL EXAMINATION RESULTS USED IN DETERMINING THE CAUSE OF FETAL DEATH? FORMCHECKBOX YES FORMCHECKBOX NO11a. NAME OF CERTIFIER/ATTENDANT FORMTEXT ?????11b. NPI FORMTEXT ?????11c. TITLE FORMCHECKBOX ATTENDING FORMCHECKBOX MD / FORMCHECKBOX DO FORMCHECKBOX MEDICAL EXAMINER FORMCHECKBOX CERTIFYING FORMCHECKBOX MD / FORMCHECKBOX DO11d. ADDRESS OF CERTIFIER/ATTENDANT FORMTEXT ?????11e. SIGNATURE OF CERTIFIER/ATTENDANT11f. DATE FORMTEXT ?????12a. NAME OF PERSON COMPLETING REPORT FORMTEXT ?????12b. TITLE FORMTEXT ?????12c. DATE REPORT COMPLETED (MM/DD/YYYY) FORMTEXT ?????13. DISPOSITION FORMCHECKBOX BURIAL FORMCHECKBOX CREMATION FORMCHECKBOX HOSPITAL DISPOSITION FORMCHECKBOX DONATION FORMCHECKBOX REMOVAL FROM STATE FORMCHECKBOX OTHER (Specify): FORMTEXT ?????14. NAME OF CEMETERY OR CREMATORY FORMTEXT ?????15a. CITY/TOWN FORMTEXT ?????15b. STATE FORMTEXT ?????16. NAME AND ADDRESS OF FUNERAL HOME FORMTEXT ?????17a. NAME OF FUNERAL DIRECTOR (Print or Type) FORMTEXT ?????17b. SIGNATURE OF FUNERAL DIRECTOR17c. NJ LICENSE NO. FORMTEXT ?????18a. NAME OF REGISTRAR (Print or Type) FORMTEXT ?????18b. SIGNATURE OF REGISTRAR18c. DATE RECEIVED BY REGISTRAR (MM/DD/YYYY FORMTEXT ????? New Jersey Department of HealthCERTIFICATE OF FETAL DEATHSTATE FILE NO.THE FOLLOWING CONFIDENTIAL INFORMATION MAY BE USED IN CONNECTION WITH RESEARCH STUDIES APPROVED BY THE PUBLIC HEALTH COUNCIL AS AUTHORIZED BY CHAPTER 68, P.L. 1963. SUCH INFORMATION WILL NOT APPEAR ON ANY CERTIFIED COPY OF THIS RECORD.19a. MOTHER’S EDUCATION (Check the box that best describes the highest degree or level of school completed at the time of delivery.) FORMCHECKBOX 8th grade or less FORMCHECKBOX 9th-12th grade, no diploma FORMCHECKBOX High school graduate or GED completed FORMCHECKBOX Some college credit but no degree FORMCHECKBOX Associate degree (e.g., AA, AS) FORMCHECKBOX Bachelor’s degree (e.g., BA, AB, BS) FORMCHECKBOX Master’s degree (e.g., MA, MS, MEng, MEd, MSW, MBA) FORMCHECKBOX Doctorate (e.g., PhD, EdD) or Professional degree (e.g. MD. DDS, DVM, LLB, JD)20a. MOTHER’S HISPANIC ORIGIN (Check the box that best describes whether the mother is Spanish/Hispanic/Latina. Check the “No” box if mother is not Spanish/Hispanic/Latina.) FORMCHECKBOX No, not Spanish/Hispanic/Latina FORMCHECKBOX Yes, Mexican, Mexican American, Chicana FORMCHECKBOX Yes, Puerto Rican FORMCHECKBOX Yes, Cuban FORMCHECKBOX Yes, other Spanish/Hispanic/Latina (Specify): FORMTEXT ___________________21a. MOTHER’S RACE (Check one or more races to indicate what the mother considers herself to be.) FORMCHECKBOX White FORMCHECKBOX Black or African American FORMCHECKBOX American Indian or Alaska Native (Name?of?enrolled?or?principal?tribe): FORMTEXT _________________ FORMCHECKBOX Asian Indian FORMCHECKBOX Chinese FORMCHECKBOX Filipina FORMCHECKBOX Japanese FORMCHECKBOX Korean FORMCHECKBOX Vietnamese FORMCHECKBOX Other Asian (Specify): FORMTEXT ___________ FORMCHECKBOX Native Hawaiian FORMCHECKBOX Guamanian or Chamorro FORMCHECKBOX Samoan FORMCHECKBOX Other Pacific Islander (Specify): FORMTEXT ___________ FORMCHECKBOX Other (Specify): FORMTEXT ___________19b. FATHER’S EDUCATION (Check the box that best describes the highest degree or level of school completed at the time of delivery.) FORMCHECKBOX 8th grade or less FORMCHECKBOX 9th-12th grade, no diploma FORMCHECKBOX High school graduate or GED completed FORMCHECKBOX Some college credit but no degree FORMCHECKBOX Associate degree (e.g., AA, AS) FORMCHECKBOX Bachelor’s degree (e.g., BA, AB, BS) FORMCHECKBOX Master’s degree (e.g., MA, MS, MEng, MEd, MSW, MBA) FORMCHECKBOX Doctorate (e.g., PhD, EdD) or Professional degree (e.g. MD. DDS, DVM, LLB, JD)20b. FATHER’S HISPANIC ORIGIN (Check the box that best describes whether the father is Spanish/Hispanic/Latino. Check the “No” box if father is not Spanish/Hispanic/Latino.) FORMCHECKBOX No, not Spanish/Hispanic/Latino FORMCHECKBOX Yes, Mexican, Mexican American, Chicano FORMCHECKBOX Yes, Puerto Rican FORMCHECKBOX Yes, Cuban FORMCHECKBOX Yes, other Spanish/Hispanic/Latino (Specify): FORMTEXT ___________________21b. FATHER’S RACE (Check one or more races to indicate what the father considers himself to be.) FORMCHECKBOX White FORMCHECKBOX Black or African American FORMCHECKBOX American Indian or Alaska Native (Name?of?enrolled?or?principal?tribe): FORMTEXT _________________ FORMCHECKBOX Asian Indian FORMCHECKBOX Chinese FORMCHECKBOX Filipino FORMCHECKBOX Japanese FORMCHECKBOX Korean FORMCHECKBOX Vietnamese FORMCHECKBOX Other Asian (Specify): FORMTEXT ___________ FORMCHECKBOX Native Hawaiian FORMCHECKBOX Guamanian or Chamorro FORMCHECKBOX Samoan FORMCHECKBOX Other Pacific Islander (Specify): FORMTEXT ___________ FORMCHECKBOX Other (Specify): FORMTEXT ___________22. OCCUPATION DURING THE PAST YEAR23. BUSINESS/INDUSTRY WORKED AT DURING THE PAST YEARa. Mother: FORMTEXT ?????a. Mother: FORMTEXT ?????b. Father: FORMTEXT ?????b. Father: FORMTEXT ?????24. MOTHER MARRIED? (At delivery, conception, or any time between) FORMCHECKBOX Yes FORMCHECKBOX No25. DATE LAST NORMAL MENSES BEGAN (MM/DD/YYYY) FORMTEXT _____/ FORMTEXT _____/ FORMTEXT _____Month / Day / Year26. DATE OF FIRST PRENATAL CARE VISIT (MM/DD/YYYY) FORMTEXT _____/ FORMTEXT _____/ FORMTEXT _____Month / Day / Year FORMCHECKBOX No Prenatal Care27. DATE OF LAST PRENATAL CARE VISIT (MM/DD/YYYY) FORMTEXT _____/ FORMTEXT _____/ FORMTEXT _____Month / Day / Year28. TOTAL NUMBER OF PRENATAL VISITS FOR THIS PREGNANCY(If “None”, enter “0”) FORMTEXT ?????29a. NUMBER OF PREVIOUS LIVE BIRTHS, NOW LIVINGNumber: FORMTEXT ________ FORMCHECKBOX None29a. NUMBER OF PREVIOUS LIVE BIRTHS, NOW DEADNumber: FORMTEXT _____ FORMCHECKBOX None29c. DATE OF LAST LIVE BIRTH (MM/YYYY) FORMTEXT _____/ FORMTEXT _____Month / Year30a. NUMBER OF OTHER PREGNANCY OUTCOMES (spontaneous or induced losses or ectopic pregnancies) (Do not include this fetus)Number: FORMTEXT ________ FORMCHECKBOX None30b. DATE OF LAST OTHER PREGNANCY OUTCOME (MM/YYYY) FORMTEXT _____/ FORMTEXT _____Month / Year31. MOTHER’S HEIGHT (feet/inches) FORMTEXT ________32. MOTHER’S PRE-PREGNANCY WEIGHT (pounds) FORMTEXT ________33. MOTHER’S WEIGHT AT DELIVERY (pounds) FORMTEXT ________34. DID MOTHER GET WIC FOOD FOR HERSELF DURING THIS PREGNANCY? FORMCHECKBOX Yes FORMCHECKBOX No35a. CIGARETTE SMOKING BEFORE AND DURING PREGNANCY (FOR EACH TIME PERIOD, ENTER EITHER THE AVERAGE NUMBER OF CIGARETTES OR THE AVERAGE NUMBER OF PACKS OF CIGARETTES SMOKED PER DAY.) IF NONE, ENTER “0”.Three Months Before Pregnancy: FORMTEXT ________ number of cigarettes OR FORMTEXT ________ number of packsFirst Three Months of Pregnancy: FORMTEXT ________ number of cigarettes OR FORMTEXT ________ number of packsSecond Three Months of Pregnancy: FORMTEXT ________ number of cigarettes OR FORMTEXT ________ number of packsThird Trimester of Pregnancy: FORMTEXT ________ number of cigarettes OR FORMTEXT ________ number of packs35b. OTHER RISK FACTORS FOR THIS PREGNANCY (Complete all items)Alcohol Use during pregnancy? FORMCHECKBOX Yes FORMCHECKBOX No Average number of drinks per week: FORMTEXT ________Homelessness? FORMCHECKBOX Yes FORMCHECKBOX NoDomestic Violence? FORMCHECKBOX Yes FORMCHECKBOX NoUse of cocaine, heroin, marijuana, or methamphetamines during pregnancy? FORMCHECKBOX Yes FORMCHECKBOX NoNAME OF FETUS (First, Middle, Last) FORMTEXT ?????REG-26JUL 18Page 2 of 3 Pages.New Jersey Department of HealthCERTIFICATE OF FETAL DEATHSTATE FILE NO.36a. MOTHER TRANSFERRED FOR MATERNAL MEDICAL OR FETAL INDICATIONS FOR DELIVERY? FORMCHECKBOX No FORMCHECKBOX Yes IF YES, ENTER NAME OF FACILITY MOTHER TRANSFERRED FROM: FORMTEXT ?????36b. MUNICIPALITY NAME FORMTEXT ?????36c. COUNTY NAME FORMTEXT ?????MEDICAL AND HEALTH INFORMATION37. MEDICAL RISK FACTORS FOR THIS PREGNANCY (Check all that apply) FORMCHECKBOX Anemia (Hct. <30 / Hgb. <10) FORMCHECKBOX Cardiac disease FORMCHECKBOX Acute or chronic lung disease FORMCHECKBOX Diabetes, Prepregnancy (diagnosis prior to this pregnancy) FORMCHECKBOX Diabetes, Gestational (diagnosis in this pregnancy) FORMCHECKBOX Genital herpes FORMCHECKBOX Hydramnios/Oligohydramnios FORMCHECKBOX Hemoglobinopathy FORMCHECKBOX Hypertension, Prepregnancy (Chronic) FORMCHECKBOX Hypertension, Gestational (PIH, preeclampsia) FORMCHECKBOX Hypertension, Eclampsia FORMCHECKBOX Incompetent cervix FORMCHECKBOX Previous infant 4000+ grams FORMCHECKBOX Previous preterm birth FORMCHECKBOX Other previous poor pregnancy outcome (includes perinatal death, small-for-gestational age/intrauterine growth-restricted birth) FORMCHECKBOX Renal Disease FORMCHECKBOX Rh sensitization FORMCHECKBOX Uterine bleeding FORMCHECKBOX Pregnancy resulted from infertility treatment; if Yes, check all that apply: FORMCHECKBOX Fertility-enhancing drugs, artificial insemination or intrauterine insemination FORMCHECKBOX Assisted reproductive technology [e.g., in vitro fertilization (IVF), gamete intrafallopian transfer (GIFT)] FORMCHECKBOX Mother had a previous cesarean delivery; if Yes, how many? FORMTEXT ________ FORMCHECKBOX Other (Specify): FORMTEXT ____________ FORMCHECKBOX None of the above40.MATERNAL MORBIDITY (COMPLICATIONS OF LABOR AND/OR DELIVERY)(Check all that apply) FORMCHECKBOX Febrile (>100 F. or 38 C.) FORMCHECKBOX Meconium, moderate/heavy FORMCHECKBOX Premature rupture of membrane (>12 hours) FORMCHECKBOX Abruptio placenta FORMCHECKBOX Placenta previa FORMCHECKBOX Other excessive bleeding FORMCHECKBOX Seizures during labor FORMCHECKBOX Precipitous labor (<3 hours) FORMCHECKBOX Prolonged labor (>20 hours) FORMCHECKBOX Dysfunctional labor FORMCHECKBOX Breech/Malpresentation FORMCHECKBOX Cephalopelvic disproportion FORMCHECKBOX Cord prolapse FORMCHECKBOX Anesthetic complications FORMCHECKBOX Fetal distress FORMCHECKBOX Maternal transfusion FORMCHECKBOX Third or fourth degree perineal laceration FORMCHECKBOX Ruptured uterus FORMCHECKBOX Unplanned hysterectomy FORMCHECKBOX Admission to intensive care unit FORMCHECKBOX Unplanned operating room procedure following delivery FORMCHECKBOX Other (Specify): FORMTEXT ________________ FORMCHECKBOX None of the above42.CONGENITAL ANOMALIES OF FETUS (PRESENT OR KNOWN TO EXIST) (Check all that apply) FORMCHECKBOX Anencephaly FORMCHECKBOX Meningomyelocele/Spina bifida FORMCHECKBOX Hydrocephalus FORMCHECKBOX Microcephalus FORMCHECKBOX Other CNS anomalies (Specify): FORMTEXT ________________ FORMCHECKBOX Heart malformations FORMCHECKBOX Cyanotic congenital heart disease FORMCHECKBOX Congenital diaphragmatic hernia FORMCHECKBOX Other circulatory/respiratories anomalies(Specify): FORMTEXT ________________ FORMCHECKBOX Omphalocele FORMCHECKBOX Gastroschisis FORMCHECKBOX Rectal atresia / stenosis FORMCHECKBOX Tracheo-esophageal fistula / Esophageal atresia FORMCHECKBOX Other gastrointestinal anomalies (Specify): FORMTEXT ________________ FORMCHECKBOX Malformed genitalia FORMCHECKBOX Renal agenesis FORMCHECKBOX Other urogenital anomalies (Specify): FORMTEXT ________________ FORMCHECKBOX Polydactyly / Syndactyly / Adactyly FORMCHECKBOX Club foot FORMCHECKBOX Limb reduction defect (excluding congenital amputation and dwarfing syndromes) FORMCHECKBOX Other musculoskeletal / integumental anomalies (Specify): FORMTEXT ________________ FORMCHECKBOX Cleft Lip with or without Cleft Palate FORMCHECKBOX Cleft Palate alone FORMCHECKBOX Down Syndrome FORMCHECKBOX Karyotype confirmed FORMCHECKBOX Karyotype pending FORMCHECKBOX Suspected chromosomal disorder FORMCHECKBOX Karyotype confirmed FORMCHECKBOX Karyotype pending FORMCHECKBOX Other chromosomal anomalies (Specify): FORMTEXT ________________ FORMCHECKBOX Hypospadias FORMCHECKBOX Other(Specify): FORMTEXT ________________ FORMCHECKBOX None of the anomalies listed above41. METHOD OF DELIVERY (Check all that apply)A.Was delivery with forceps attempted but unsuccessful? FORMCHECKBOX Yes FORMCHECKBOX NoB.Was delivery with vacuum extraction attempted but unsuccessful? FORMCHECKBOX Yes FORMCHECKBOX NoC.Fetal presentation at delivery: FORMCHECKBOX Cephalic FORMCHECKBOX Breech FORMCHECKBOX OtherD.Final route and method of delivery (Check?one) FORMCHECKBOX D&E FORMCHECKBOX Vaginal/Spontaneous FORMCHECKBOX Vaginal/Forceps FORMCHECKBOX Vaginal/VacuumIf vaginal, was vaginal birth after previous Cesarean section? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Cesarean, Primary FORMCHECKBOX Cesarean, RepeatIf cesarean, was a trial of labor attempted? FORMCHECKBOX Yes FORMCHECKBOX NoE.Hysterotomy/Hysterectomy FORMCHECKBOX Yes FORMCHECKBOX No38. INFECTIONS PRESENT AND/OR TREATED DURING THIS PREGNANCY (Check all that apply) FORMCHECKBOX Gonorrhea FORMCHECKBOX Syphilis FORMCHECKBOX Chlamydia FORMCHECKBOX Listeria FORMCHECKBOX Group B Streptococcus FORMCHECKBOX Cytomegalovirus FORMCHECKBOX Parvovirus FORMCHECKBOX Toxoplasmosis FORMCHECKBOX None of the above FORMCHECKBOX Other (Specify): FORMTEXT ________________39. OBSTETRIC PROCEDURES(Check all that apply) FORMCHECKBOX None FORMCHECKBOX Amniocentesis FORMCHECKBOX Electronic fetal monitoring FORMCHECKBOX Induction of labor FORMCHECKBOX Stimulation of labor FORMCHECKBOX Tocolysis FORMCHECKBOX Ultrasound FORMCHECKBOX Other (Specify): FORMTEXT ____________NAME OF FETUS (First, Middle, Last) FORMTEXT ?????REG-26JUL 18Page 3 of 3 Pages. ................
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