4. Deaths Newborn Deaths. Delivered at the Center and Died within Seven Days of Life. Do not include clients transferred more than 48 hours before birth. Birth Death Occurred at Reported to Date Weight, Cause of Death Medical Grams Hospital Home Other Examiner, Y/N Center Stillborn/Fetal Deaths. Delivered at the Birth Center only. Birth Death Occurred Reported to Date Weight, Cause of Death Medical Before During During Grams Examiner, Y/N Labor Labor Delivery 5. Signature The information presented on this form is true and correct. Prepared by: Date of Submission: Signature Title Printed Name Telephone RETURN THIS COMPLETED FORM TO Fax: (850) 488-5897 Email: Agency for Health Care Administration Hospital and Outpatient Services Unit 2727 Mahan Dr., MS 31 Tallahassee, FL 32308-5407
4. Deaths Newborn Deaths. Delivered at the Center and Died within Seven Days of Life. Do not include clients transferred more than 48 hours before birth. Date Birth Weight, Grams Death Occurred at Cause of Death Reported to Medical Examiner, Y/N Center Hospital Home Other Stillborn/Fetal Deaths. Delivered at the Birth Center only. Date Birth Weight, Grams Death Occurred Cause of Death Reported to Medical Examiner, Y/N Before Labor During Labor During Delivery 5. Signature The information presented on this form is true and correct. Prepared by: Date of Submission: Signature Title Printed Name Telephone RETURN THIS COMPLETED FORM TO Fax: (850) 488-5897 Email: Agency for Health Care Administration Hospital and Outpatient Services Unit 2727 Mahan Dr., MS 31 Tallahassee, FL 32308-5407
Birth_Center_Annual_Report_3130-3004_February_2015.docx