UV_Vital Records Birth and Fetal Death Reporting
1.1.0 - STU 1.1

UV_Vital Records Birth and Fetal Death Reporting, published by IHE International. This guide is not an authorized publication; it is the continuous build for version 1.1.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/IHE/fhir-bfdr/ and changes regularly. See the Directory of published versions

## Questionnaire: Questionnaire - Patient's Fetal Death Worksheet

Official URL: https://profiles.ihe.net/QRPH/bfdr/Questionnaire/Questionnaire-patients-fetal-death | Version: 1.1.0
Draft as of 2024-07-09 | Computable Name: QuestionnairePatientsFetalDeathWorksheet

This Questionnaire represents the Patient’s Worksheet for the Report of Fetal Death.

Generated Narrative: Questionnaire Questionnaire-patients-fetal-death

version: versionId: id (PrimitiveType/Questionnaire.meta.versionId): native = id -> 12; Last updated: 2021-07-09 07:23:29+0000

LinkID | Text | Cardinality | Type | Description & Constraints
--- | --- | --- | --- | ---
QuestionnairePatientsFetalDeathWorksheet | This Questionnaire represents the [Patient's Worksheet for the Report of Fetal Death](https://www.cdc.gov/nchs/data/dvs/fetal-death-mother-worksheet-english-2019-508.pdf). |  | Questionnaire | https://profiles.ihe.net/QRPH/bfdr/Questionnaire/Questionnaire-patients-fetal-death#1.1.0
intro | We are truly sorry about the loss you have experienced. We understand that this is a difficult time for you and your loved ones. We need to ask you a few questions to assist in the completion of the official report of fetal death. State laws provide protection against the unauthorized release of identifying information from the report of fetal death to ensure confidentiality of the parents. This information may also help researchers understand some of the factors that are related to miscarriage and stillbirth. Your assistance in providing complete and accurate information is very important. We appreciate your help, especially during this very difficult time. | 0..1 | display |
child-name | 1. Would you like to name the child? This is entirely optional. | 0..1 | group |
child-first-name | First | 0..1 | string |
child-middle-name | Middle | 0..1 | string |
child-last-name | Last | 0..1 | string |
child-suffix | Suffix (Jr., III, etc.) | 0..1 | string |
mother-current-legal-name | 2. What is your current legal name? | 0..1 | group |
mother-first-name | First | 0..1 | string |
mother-middle-name | Middle | 0..1 | string |
mother-last-name | Last | 0..1 | string |
mother-suffix | Suffix (Jr., III, etc.) | 0..1 | string |
mother-address | 3. Where do you usually live - that is - where is your household/residence located? | 0..1 | group |
mother-nbr-street | Complete number and street (do not enter rural route numbers) | 0..1 | string |
mother-apt-nbr | Apartment Number | 0..1 | string |
mother-city | City, Town, or Location | 0..1 | string |
mother-county | County | 0..1 | string |
mother-state | State (or U.S. Territory, Canadian Province) | 0..1 | string |
mother-zip | Zip Code | 0..1 | string |
mother-country | If not in the United States, country | 0..1 | string |
inside-city-limits | 4. Is this household inside city limits (inside the incorporated limits of the city, town, or location where you live)? | 0..1 | choice | Value Set: Yes No Unknown (YNU)
mother-mail | 5. What is your mailing address | 0..1 | group |
mother-mail-same | Same as residence [Go to next question] | 0..1 | boolean |
mother-mail-nbr-street | Complete number and street | 0..1 | string | Enable When: mother-mail-same =
mother-mail-apt-nbr | Apartment Number | 0..1 | string | Enable When: mother-mail-same =
mother-mail-po-box | P.O. Box | 0..1 | string | Enable When: mother-mail-same =
mother-mail-city | City, Town, or Location | 0..1 | string | Enable When: mother-mail-same =
mother-mail-state | State (or U.S. Territory, Canadian Province) | 0..1 | string | Enable When: mother-mail-same =
mother-mail-zip | Zip Code | 0..1 | string | Enable When: mother-mail-same =
mother-mail-country | If not in the United States, country | 0..1 | string | Enable When: mother-mail-same =
mother-dob | 6. What is your date of birth? | 0..1 | date |
mother-birthplace | 7. In what State, U.S. territory, or foreign country were you born? Please specify one of the following: | 0..1 | group |
mother-birthplace-state | State | 0..1 | string |
mother-birthplace-territory | or U.S. territory, i.e., Puerto Rico, U.S. Virgin Islands, Guam, American Samoa or Norther Marianas | 0..1 | string |
mother-birthplace-country | or Foreign country | 0..1 | string |
mother-education | 8. What is the highest level of schooling that you have completed at the time of delivery? (Check the box that best describes your education. If you are currently enrolled, check the box that indicates the previous grade or highest degree received). | 0..1 | choice | Value Set: Vital Records Education Level (NCHS)
mother-ethnicity | 9. Are you Spanish/Hispanic/Latina? If not Spanish/Hispanic/Latina, check the “No” box. If Spanish/Hispanic/Latina, check the appropriate box. | 0..1 | group |
mother-shl | Are you Spanish/Hispanic/Latina | 0..* | choice | Value Set: OMB Ethnicity Categories
mother-detailed-shl | If Spanish/Hispanic/Latina, check the appropriate box. | 0..1 | choice | Enable When: mother-shl = Value Set: Detailed ethnicity
mother-race | 10. What is your race? (Please check one or more races to indicate what you consider yourself to be). | 0..1 | group |
mother-race-category | Race categories | 0..* | choice | Value Set: OMB Race Categories
mother-detailed-race | Extended race codes | 0..* | choice | Value Set: Detailed Race
father-current-legal-name | 11. What is the current legal name of your baby's father? | 0..1 | group |
father-first-name | First | 0..1 | string |
father-middle-name | Middle | 0..1 | string |
father-last-name | Last | 0..1 | string |
father-suffix | Suffix (Jr., III, etc.) | 0..1 | string |
father-dob | 12. What is the father's date of birth? | 0..1 | date |
father-birthplace | 13. In what State, U.S. territory, or foreign country was the father born? Please specify one of the following: | 0..1 | group |
father-birthplace-state | State | 0..1 | string |
father-birthplace-territory | or U.S. territory, i.e., Puerto Rico, U.S. Virgin Islands, Guam, American Samoa or Norther Marianas | 0..1 | string |
father-birthplace-country | or Foreign country | 0..1 | string |
receive-wic | 14. Did you receive WIC (Women, Infants and Children) food for yourself during this pregnancy? | 0..1 | choice | Value Set: Yes No Unknown (YNU)
mothers-height | 15. What is your height? | 0..1 | group |
mothers-height-feet | Feet | 0..1 | quantity |
mothers-height-inches | Inches | 0..1 | quantity |
mothers-prepregnancy-weight | 16. lbs | 0..1 | quantity |
mothers-smoking | 17. How many cigarettes OR packs of cigarettes did you smoke on an average day during each of the following time periods? If you NEVER smoked, enter zero for each time period. | 0..1 | group |
mothers-smoking-3-months-prior | Three months before pregnancy | 0..1 | group |
mothers-smoking-3-months-prior-cig | # of cigarettes* | 0..1 | integer |
mothers-smoking-3-months-prior-pck | # of packs | 0..1 | integer |
mothers-smoking-trimester-1 | First three months of pregnancy | 0..1 | group |
mothers-smoking-trimester-1-cig | # of cigarettes* | 0..1 | integer |
mothers-smoking-trimester-1-pck | # of packs | 0..1 | integer |
mothers-smoking-trimester-2 | Second three months of pregnancy | 0..1 | group |
mothers-smoking-trimester-2-cig | # of cigarettes* | 0..1 | integer |
mothers-smoking-trimester-2-pck | # of packs | 0..1 | integer |
mothers-smoking-trimester-3 | Third trimester of pregnancy | 0..1 | group |
mothers-smoking-trimester-3-cig | # of cigarettes* | 0..1 | integer |
mothers-smoking-trimester-3-pck | # of packs | 0..1 | integer |
cigarette-note | *refers to tobacco products only, NOT e-cigarettes. | 0..1 | display |
outro | Thank you for completing this worksheet at this very difficult time. The information you have provided is very important; it will be used by researchers to better understand factors related to miscarriage and stillbirth and lead to improved prevention strategies for the future. | 0..1 | display |
Documentation for this format