Fetal Death Report Form

Reporting Person Name

First NameMiddle NameLast Name

Role / Title

Facility / Organization Name

Department / Unit

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Email Address

example@example.com

Date and Time of Report

Date

Hour MinutesAM/PM Option

Report Reference / Case Number

Mother's Full Name

First NameMiddle NameLast Name

Mother's Age

Mother's Address or Location

Street Address

Street Address Line 2

CityState / ProvincePostal / Zip CodeCountry

Contact Number

Please enter a valid phone number.Format: (000) 000-0000.

Gestational Age at Time of Fetal Death (weeks)

Number of Pregnancies

Number of Prior Live Births or Fetal Losses

Date fetal death was known or discovered

Date

Hour MinutesAM/PM Option

Time fetal death was known or discovered

Hour Minutes

AM/PM Option

Place of occurrence

Timing relative to labor and delivery

Sex of fetus

Fetal weight (grams)

Estimated fetal weight (grams)

Plurality

Visible condition or notable findings

Prenatal care status

Type of pregnancy care received

Delivery method

Complications during pregnancy or delivery

Suspected cause or contributing circumstances

Autopsy or examination performed

Referral or follow-up needed

Referral or follow-up details

Certifier or Completing Clinician Name

First NameMiddle NameLast Name

Certifier Title

Date Signed/Completed

Date

Remarks or Additional Notes

Fetal Death Report Form

Reporter and Facility Information

Mother and Pregnancy Information

Fetal Death Details

Pregnancy, Delivery, and Clinical Circumstances

Certification and Follow-up