Child Death Case Review Systems Agreement

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Appendix B HIP AA Required Elements to De-Identify Case Data * These data elements will be removed for all persons accessing de-identified case data, per the Data Use Agreement. The source of these data elements is the National Center for Review and Prevention of Child Deaths' Case Reporting System: Case Report Tool. Introduction: Case Definition Case number County of review Review team number Sequence of review Death certificate number Birth certificate number Medical examiner/Coroner number Section A: Child Information Child first name Child middle name Child last name Child name: unknown Date of birth: month, day, and year Date of birth: unknown Date of death: month and day Date of death: unknown Residential address: unknown Residential address: street Residential address: apartment Residential address: city Residential address: county Residential address: zip Section D: Incident Information Date of incident Date of incident: same Date of incident: unknown Time of incident Time of incident: am or pm Time of incident: unknown Incident County Death County Section N: Form Completed By The names and contact information will be removed . • • Source: http://www.hhs.gov/ocr/combinedregtext.pdf, Section 164.514(b )(2)(i) of the rules. 9