Child Death Review Case Reporting System Data Use Agreement

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