DeathCertificateReleaseAuthorizationForm-Child

Full Name of Deceased Child

Sex of child: Male Female Date of Death or Stillbirth: /  / 

Month Day Year

Place of Death or Stillbirth- Hospital/Clinic (if applicable)

______________________________________ 

Place of Death or Stillbirth- City Place of Death or Stillbirth- State

______________________________________ ______________________________________

Name of Doctor (if applicable) Name of Funeral Director

Place of Burial

- - Not applicable

Social Security Number of Deceased

The measurement of children’s health is a primary research aim of the National Children’s Study (NCS). Information from the death certificate will only be used for statistical purposes in health research. We are asking you to authorize the state office of vital records to release the death certificate information of the child named above to researchers from the NCS.

Your child’s death certificate information will be used for research purposes only. All information will be kept strictly confidential. Names and other identifying information will not be released without your permission.

 I PERMIT the NCS to obtain my child’s death certificate information.

 I DO NOT PERMIT the NCS to obtain my child’s death certificate information.

_________________________________________ _________________________________________________

Printed parent/guardian name (first, middle, last) Signature of parent/guardian

_________________________________________________

Relationship to Child

Date signed: // - -

m m d d y y y y Phone number

Questions related to the collection of health‐related death certificate information can be answered by NCS staff at 1-877-865-2619.

CON HIPAA Authorization Form for Release of Child Death Certificate, MDES 3.5, V2.0 0