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NATIONAL CENTER FOR THE REVIEW AND PREVENTION OF CHILD DEATHS <br />CASE REPORTING SYSTEM <br />Application for De -identified Dataset <br />Please complete information electronically. <br />I. Data <br />A. For what year or years of the NCRPCD Case Reporting System are data requested? <br />2004 <br />2005 <br />2006 _ <br />2007 <br />2008 <br />2009 <br />2010 <br />2011 <br />2012 <br />2013 <br />Note: States have different timeframes for when cases are reviewed and entered into the CDR <br />Case Reporting System. Only cases that have been identified and approved by the states as being <br />complete and clean will be included in the de -identified dataset. NCRPCD will survey states on <br />an annual basis to make this determination. <br />Cases migrated from previous child death review reporting systems into the CDR Case <br />Reporting System will not be included in a standard dataset, but may be provided upon further <br />consultation between the researcher and NCRPCD. <br />II. Investigator/researchers <br />A. Identify the Principal Investigator who will carry out the duties described in the <br />Guidelines and provide his/her curriculum vitae as an attachment: <br />Name: <br />Title: <br />Institution: <br />Department: <br />Street address: <br />City: <br />State: <br />Zip: <br />Phone: <br />Email address: <br />19 <br />