Infant Mortality Survey
Help us understand the factors related to infant mortality by completing this survey. Your responses will contribute to important research and improved care.
Your relationship to the infant
*
Parent/Guardian
Healthcare Provider
Relative
Other
Infant's gender
*
Male
Female
Other/Unknown
Infant's date of birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Infant's age at time of death (in months)
*
Birth weight (in grams)
Gestational age at birth (in weeks)
Place of infant's death
*
Home
Hospital
During transport
Other
Suspected cause of death
Please Select
Infection
Prematurity
Birth complications
Congenital anomaly
Sudden Infant Death Syndrome (SIDS)
Unknown
Other
Maternal information
Rows
Yes
No
Unknown
Mother received prenatal care
1
2
3
Mother had any known medical conditions
4
5
6
Mother used tobacco/alcohol during pregnancy
7
8
9
Please rate the following factors that may have contributed to the infant's death
Rows
Not a factor
Minor factor
Major factor
Unknown
Limited access to healthcare
10
11
12
13
Poor nutrition
14
15
16
17
Infections
18
19
20
21
Unsafe living conditions
22
23
24
25
Delayed medical attention
26
27
28
29
Additional comments or observations
Submit Survey
Should be Empty: