Please print neatlyFETAL DEATH REPORT FACILITY WORKSHEETCenter for Health StatisticsOnly use this form to report a Fetal Death Do NOT file a fetal death report if the delivery resulted in a live birth,.
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How to use or fill out the OR Fetal Death Report online
Filling out the OR Fetal Death Report is an important step in documenting a fetal death accurately and compassionately. This guide provides clear instructions for users to complete the report online, ensuring all necessary information is captured in a respectful manner.
Follow the steps to complete the OR Fetal Death Report online.
- Press the ‘Get Form’ button to obtain the OR Fetal Death Report and open it for editing.
- Begin by providing the fetus's name in the designated fields for first, middle, last, and suffix, as well as the date and time of delivery.
- Indicate the sex of the fetus, choosing from male, female, or undetermined.
- Select the appropriate method of disposition for the fetus, specifying whether it was released to the parents or a funeral home.
- Fill in the mother's health information, including prenatal care through WIC, height, weight, cigarette use, and details about previous live births.
- Provide information regarding risk factors related to the pregnancy, including any pre-existing conditions such as diabetes or hypertension.
- Detail the delivery method and fetal presentation, including specifics about any complications encountered during delivery.
- Document the weight of the fetus, gestation period, and plurality.
- Identify causes or conditions that contributed to the fetal death by selecting from the provided options and specifying any other significant conditions.
- Indicate the estimated time and circumstances of the fetal death, including whether an autopsy or histological examination was performed.
- Provide the name and title of the attendant at delivery, along with the ID tag number obtained from the funeral home.
- Review all entered information for accuracy, then save changes, download, print, or share the completed form as needed.
Complete the OR Fetal Death Report online to ensure precise documentation and support for the involved parties.
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