Form 0920-19BDE Data Abstraction

Contents
Home Record ..............................................................................................................................................................4
Birth/Fetal Death Certificate – Parent Section ...........................................................................................................6
Birth/Fetal Death Certificate- Infant/Fetal Section ................................................................................................. 17
Autopsy Report ........................................................................................................................................................ 20
Prenatal Care Record ............................................................................................................................................... 22
ER Visits and Hospitalizations .................................................................................................................................. 29
Other Medical Office Visits ...................................................................................................................................... 36
Medical Transport ................................................................................................................................................... 40
Social and Environmental Profile ............................................................................................................................ 43
Mental Health Profile .............................................................................................................................................. 45
Informant Interviews ............................................................................................................................................... 47

Form Approved
OMB No. XXX-XXX
Exp. Date XX/XX/XXX

Public reporting burden of this collection of information is estimated to average 15 hours per response, including the time for
reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and
reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a
collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden
estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR
Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-xxxx)

Home Record

Birth/Fetal Death Certificate – Parent Section

Birth/Fetal Death Certificate- Infant/Fetal Section

Autopsy Report

Prenatal Care Record

ER Visits and Hospitalizations

Other Medical Office Visits

Medical Transport

Social and Environmental Profile

Mental Health Profile

Informant Interviews