Vital Records Birth and Fetal Death Reporting
1.1.0 - STU 1.1 United States of America flag

This page is part of the Vital Records Birth and Fetal Death Reporting (v1.1.0: STU 1) based on FHIR R4. This is the current published version in its permanent home (it will always be available at this URL). For a full list of available versions, see the Directory of published versions

Example QuestionnaireResponse: QuestionnaireResponse - Patient's Fetal Death Worksheet: Carmen Lee

LinkIdTextDefinitionAnswerdoco
.. QuestionnaireResponse-patients-fetal-death-carmen-leeQuestionnaire:Questionnaire - Patient's Worksheet for the Report of Fetal Death
... mother-current-legal-nameWhat is your current legal name?
.... mother-first-nameFirstCarmen
.... mother-middle-nameMiddleTeresa
.... mother-last-nameLastLee
... mother-addressWhere do you usually live - that is - where is your household/residence located?
.... mother-nbr-streetComplete number and street (do not enter rural route numbers)3670 Miller Road
.... mother-cityCity, Town, or Location
.... mother-stateState (or U.S. Territory, Canadian Province)MI
.... mother-zipZip Code48103
... inside-city-limitsIs this household inside city limits (inside the incorporated limits of the city, town, or location where you live)?expandedYes-NoIndicator N: No
... mother-mailWhat is your mailing address
.... mother-mail-sameSame as residence [Go to next question]true
... mother-dobWhat is your date of birth?1986-02-15
... mother-birthplaceIn what State, U.S. territory, or foreign country were you born? Please specify one of the following:
.... mother-birthplace-territoryor U.S. territory, i.e., Puerto Rico, U.S. Virgin Islands, Guam, American Samoa or Norther MarianasPR
... mother-educationWhat 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).urn:oid:2.16.840.1.114222.4.5.274 PHC1449: 9th through 12th grade; no diploma
... mother-ethnicityAre you Spanish/Hispanic/Latina? If not Spanish/Hispanic/Latina, check the “No” box. If Spanish/Hispanic/Latina, check the appropriate box.
.... mother-shlAre you Spanish/Hispanic/LatinaRace & Ethnicity - CDC 2135-2: Hispanic or Latino
... mother-raceWhat is your race? (Please check one or more races to indicate what you consider yourself to be).
.... mother-race-categoryRace categoriesRace & Ethnicity - CDC 2054-5: Black or African American
... father-current-legal-nameWhat is the current legal name of your baby's father?
.... father-first-nameFirstTom
.... father-middle-nameMiddleYan
.... father-last-nameLastLee
... father-dobWhat is the father's date of birth?1984-02-27
... father-birthplaceIn what State, U.S. territory, or foreign country was the father born? Please specify one of the following:
.... father-birthplace-stateStateNY
... receive-wicDid you receive WIC (Women, Infants and Children) food for yourself during this pregnancy?expandedYes-NoIndicator N: No
... mothers-heightWhat is your height?
.... mothers-height-inchesInches65 [in_i]
... mothers-prepregnancy-weightlbs180 [lb_av]
... mothers-smokingHow 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.
.... mothers-smoking-3-months-priorThree months before pregnancy
..... mothers-smoking-3-months-prior-cig# of cigarettes*0
..... mothers-smoking-3-months-prior-pck# of packs0
.... mothers-smoking-trimester-1First three months of pregnancy
..... mothers-smoking-trimester-1-cig# of cigarettes*0
..... mothers-smoking-trimester-1-pck# of packs0
.... mothers-smoking-trimester-2Second three months of pregnancy
..... mothers-smoking-trimester-2-cig# of cigarettes*0
..... mothers-smoking-trimester-2-pck# of packs0
.... mothers-smoking-trimester-3Third trimester of pregnancy
..... mothers-smoking-trimester-3-cig# of cigarettes*0
..... mothers-smoking-trimester-3-pck# of packs0

doco Documentation for this format