5-C:75 Death Report Forms. –
A completed fetal death report shall consist of the following:
I. The name of the fetus, if named.
II. If not named, the first and middle names shall be listed as given names or as "baby girl" or "baby boy."
III. The name of the hospital or the street and number of the location of delivery.
IV. The city, town, or location, and county of delivery.
V. The date of delivery.
VI. The sex of the fetus.
VII. Information regarding the mother including her: full name, maiden surname, date of birth, residence, race, ancestry, education, occupation, and social security number.
VIII. If available, the same information regarding the father as that provided in paragraph VII regarding the mother.
IX. Statistical information regarding the pregnancy including:
(a) The number of live births of children now living and now dead.
(b) The date of the last live birth by month and year.
(c) The number of other terminations, spontaneous or induced, at any time after conception.
(d) The date of the last other termination by month and year.
(e) Whether the mother was married at the time of delivery, conception, or any time between.
(f) The date that the last normal menses began by month, day, and year.
(g) The month of pregnancy in which prenatal care began, such as first, second, or third.
(h) The total number of prenatal visits.
(i) The weight of the fetus.
(j) The clinical estimate of gestation, in weeks.
(k) Whether the fetus was single, twin, triplet or more.
(l) The birth order, if not a single birth.
X. Medical information regarding the pregnancy including:
(a) The medical risk factors for the pregnancy.
(b) Any other risk factors, such as, but not limited to, tobacco or alcohol use.
(c) The obstetrical procedures employed.
(d) Any complications of labor or delivery.
(e) The method of delivery.
(f) Any congenital anomalies.
XI. Information regarding the fetal death, including:
(a) The fetal or maternal condition directly causing death.
(b) Any condition of which death was a consequence or to which it was due, either fetal or maternal.
(c) The conditions giving rise to the immediate cause of death.
(d) Any other significant conditions of fetus or mother contributing to fetal death but not related to immediate cause.
(e) Whether the fetus died before labor or during labor or delivery.
(f) Whether an autopsy was performed.
(g) Whether autopsy findings were considered in determining the cause of death.
(h) The delivery attendant's name and title.
(i) The name and title of the individual completing the report.
XII. Any other applicable information regarding the fetus including: the manner of final disposition or, if disposition is outside of the hospital, the name of the cemetery or crematory and location by city or town and state.
XIII. The name and address of the funeral home, next of kin, or designated agent and the signature of the funeral director, next of kin, or designated agent, the license number of the funeral director, if applicable, and the date signed.
XIV. The signature of the hospital administrator, or designee, and the date signed.