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Attachment 1 <br />HIP AA Required Elements to De-identify Case Data * <br />These data elements will be removed for all persons accessing de-identified case data, per <br />the Data Use Agreement. The source ofthese data elements is the National Center for <br />Child Death Review Case Reporting System: Case Report Tool. <br />II/trod/wllon: '(I .I't'Definirioll <br />Case number <br />County of review <br />Review team number <br />Sequence of review <br />Death certificate number <br />Birth certificate number <br />ME/Coroner number <br />Scc;lirJtlli; Chlltllll(br/ll(l lirm <br />Child first name <br />Child middle name <br />Child last name <br />Child name : unknown <br />Date of birth: month, day, year <br />Date of birth: unknown <br />Date of death : month and day <br />Date of death: unknown <br />Residential address: unknown <br />Residential address : street <br />Residential address : apartment <br />Residential address : city <br />Residential address : county <br />Residential address : zip <br />.~'(!cli(J1/ 0 : Im:idem IlIlimIJatilm <br />Date of incident <br />Date of incident: same <br />Date of incident: unknown <br />Time of incident <br />Time of incident: am or pm <br />Time of incident: unknown <br />Incident County <br />Death County <br />SI/{J/ iOIl N:' ':(>rI1I ()IIlP/el l.Jd B y <br />The names and contact information will be removed . <br />• • Source: MP.;J/www .hlrs.gov /ocricombiniUlreg IQ;i l.ml.f. Section 164.514(b )(2)(i) ofthe rules. <br />29