Form Dch-0615 - Report Of Fetal Death - Michigan Department Of Community Health
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1
2STATE OF MICHIGAN
DEPARTMENT OF COMMUNITY HEALTH
_______________
121-
STATE FILE NUMBER
REPORT OF FETAL DEATH
(TYPE OR PRINT IN INK)
1. CHILD'S NAME
(First)
(Middle)
(Last)
(Suffix)
2. SEX OF CHILD
(If parents choose to
provide a name)
CHILD
3. NAME AND TITLE OF ATTENDANT
4. BIRTHWEIGHT
5. OBSTETRIC ESTIMATE OF
6. DATE OF DELIVERY
7. TIME OF DELIVERY
(Specify Unit)
GESTATION (Completed Weeks)
(Month, Day, Year)
M
8a. FACILITY NAME (If not institution, give complete address)
8b. CITY, VILLAGE, OR TOWNSHIP OF DELIVERY 8c. COUNTY OF DELIVERY
PLACE OF
DELIVERY
10. FATHER’S CURRENT LEGAL NAME (First, Middle, Last, Suffix)
9. MOTHER'S CURRENT LEGAL NAME (First, Middle, Last)
PARENT(S)
CONFIDENTIAL INFORMATION FOR ADMINISTRATIVE AND PUBLIC HEALTH USE ONLY
11. MOTHER'S FULL NAME BEFORE FIRST MARRIED IF
12. MEDICAL RECORD NUMBER
13. EXPECTED SOURCE OF PAYMENT FOR MEDICAL
DIFFERENT FROM CURRENT NAME
OF MOTHER
SERVICES (Private Insurance, Medicaid, etc.)
14c. RESIDENCE - PLACE
(Check one box and specify city name, or township)
14a. RESIDENCE OF MOTHER - STATE
14b. COUNTY OF RESIDENCE
□
____________________
INSIDE CITY OR VILLAGE OF
MOTHER
□
_________________________
INSIDE TOWNSHIP OF
□
___________________
UNINCORPORATED PLACE OF
15. RESIDENCE STREET ADDRESS
17. MOTHER’S MAILING ADDRESS IF DIFFERENT FROM RESIDENCE
16. ZIP CODE
(Street Number, City or Village, State, ZIP)
18a. MOTHER’S STATE OF BIRTH -
18c. CURRENT MARITAL STATUS
19a. FATHER'S STATE OF BIRTH -
19b. FATHER'S DATE
18b. MOTHER’S DATE
IF NOT USA, NAME COUNTRY
(Never married, married,
OF BIRTH
OF BIRTH
IF NOT USA, NAME COUNTRY
PARENT(S)
(Month, Day, Year)
divorced, separated, etc.)
(Month, Day, Year)
20c.HISPANIC
20a. RACE - American Indian, Black,
20b. ANCESTRY - Mexican, Cuban, Arab,
20d. EDUCATION - Indicate the category that best describes
ORIGIN
White, etc. (If Asian, give
English, French, Dutch, etc. (If
the highest degree or level of school completed by the
nationality, i.e. Chinese, Filipino,
American Indian, enter principal tribe.)
mother and the father
1. 8th grade or less
7. Master’s degree (MA,
etc.) (Enter all that apply)
(Enter all that apply)
MOTHER
2. 9th - 12 grade; no diploma
MS, MEng., MEd.,
YES
3. High school graduate or
MSW, MBA)
NO
GED
8. Doctorate or
4. Some college but no degree
Professional degree
5. Associate degree (AA, AS)
(PhD, EdD, MD, DO,
YES
6. Bachelor’s degree (BA,
DDS, DVM, LLB, JD)
FATHER
NO
AB, BS)
9. Unknown
24b. IF NOT SINGLE
21. DID MOTHER GET
22. DATE LAST NORMAL
23a. DATE OF FIRST
23b. DATE OF LAST
PLURALITY OF
23c. TOTAL
24a.
WIC FOOD FOR
BIRTH - Born First,
MENSES BEGAN
PRENATAL CARE
PRENATAL CARE VISIT
THIS PREGNANCY -
PRENATAL
HERSELF DURING
VISIT (Month, Day, Year)
(Month, Day, Year)
Single, Twin, Triplet,
Second, Third,
(Month, Day, Year)
CARE VISITS
THIS PREGNANCY?
etc. (Specify)
etc. (Specify)
YES
NO
}
MOTHER
25c. DO OTHERS IN
65. DID MOTHER
66. DATE
25a. MOTHER SMOKED
# of cigarettes # of packs
64a. For each time
HOUSEHOLD
Average number of cigarettes or packs
QUIT SMOKING?
MOTHER
BEFORE OR DURING
period, enter either
SMOKE?
of cigarettes smoked per day
QUIT SMOKING
PREGNANCY?
the number of
Three months before pregnancy
____
OR
____
YES
YES
cigarettes or the
YES
NO
First three months of pregnancy
____
OR
____
NO
NO
number of packs of
UNKNOWN
Second three months of pregnancy
____
OR
____
UNKNOWN
UNKNOWN
cigarettes smoked.
Last three months of pregnancy
____
OR
____
27. MOTHER TRANSFERRED FOR MATERNAL MEDICAL
28. ATTENDANT AT
26. PREGNANCY HISTORY (Complete each section)
OR FETAL INDICATIONS FOR DELIVERY?
DELIVERY
If yes, enter name of facility transferred from:
LIVE BIRTHS
26d. OTHER PREGNANCY
1
MD
NO
OUTCOMES
YES
_______________________
26a. NOW LIVING
26b. NOW DEAD
2
DO
(Spontaneous and induced
29. PLACE WHERE DELIVERY OCCURRED
3
NURSE
losses or ectopic
1
HOSPITAL
Number ____
Number____
4
CERTIFIED NURSE
pregnancies)
2
FREESTANDING BIRTHING CENTER
MIDWIFE
3
HOME - PLANNED
MEDICAL
None
None
5
CERTIFIED MIDWIFE
Number ____
4
HOME - UNPLANNED
AND
6
OTHER MIDWIFE
6
(Do not include this stillbirth)
CLINIC/DOCTORS OFFICE
HEALTH
7
OTHER
7
None
OTHER (Specfy) ___________________________
INFORMATION
26c. DATE OF LAST LIVE BIRTH
26e. DATE OF LAST OTHER
30. MOTHER'S
31b. MOTHER’S WEIGHT AT
31a. MOTHER’S PREPREGNANCY
(Month, Day, Year)
PREGNANCY OUTCOME
HEIGHT
WEIGHT (Pounds)
DELIVERY (Pounds)
(Month, Day, Year)
(Feet/Inches)
Please return to: Michigan Department of Community Health
DCH-0615 (11/13)
Vital Records & Health Statistics Section
P.O. Box 30691, Lansing, Michigan 48909
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