Form REG-26 "Certificate of Fetal Death" - New Jersey

What Is Form REG-26?

This is a legal form that was released by the New Jersey Department of Health - a government authority operating within New Jersey. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on July 1, 2018;
  • The latest edition provided by the New Jersey Department of Health;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form REG-26 by clicking the link below or browse more documents and templates provided by the New Jersey Department of Health.

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Download Form REG-26 "Certificate of Fetal Death" - New Jersey

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REG-26
STATE FILE NO.
New Jersey Department of Health
JUL 18
CERTIFICATE OF FETAL DEATH
1. NAME OF FETUS (First, Middle, Last) (OPTIONAL)
2a. DATE OF DELIVERY (Mo/Day/Yr)
2b. TIME (24 Hour)
3. SEX
4a. THIS DELIVERY
4b. IF NOT SINGLE DELIVERY, THIS FETUS DELIVERED
MALE
FEMALE
________
________
SINGLE
TWIN
OTHER
1st
2nd
OTHER
UNKNOWN/UNDETERMINED
(Specify)
(Specify)
5a. PLACE OF DELIVERY
1
HOSPITAL
3
CLINIC/DOCTOR’S OFFICE
5
OTHER (Specify):
2
FREESTANDING BIRTHING CENTER
4
HOME DELIVERY-Planned to deliver at home?
Yes
No
5b. NAME OF FACILITY (If not institution, give street address)
5c. FACILITY ID (NPI)
5d. CITY, TOWN OR LOCATION OF DELIVERY
5e. COUNTY OF DELIVERY
5f. ZIP CODE OF DELIVERY
6a. MOTHER’S CURRENT LEGAL NAME (First, Middle, Last, Suffix)
6b. DATE OF BIRTH
(Mo/Day/Yr)
6c. MOTHER’S NAME PRIOR TO FIRST MARRIAGE (List name given at birth or on birth certificate/Maiden
6d. BIRTHPLACE
(State, Territory or Foreign Country)
name)(First, Middle, Last, Suffix)
7a. RESIDENCE OF MOTHER - STATE
7b. COUNTY
7c. CITY OR TOWN
7d. STREET AND NUMBER
7e. APT NO.
7f. ZIP CODE
7g. INSIDE CITY LIMITS
(or Mother’s Mailing Address, if different from 7d)
YES
NO
8a. FATHER’S CURRENT LEGAL NAME (First, Middle, Last, Suffix)
8b. DATE OF BIRTH
8c. BIRTHPLACE
(Mo/Day/Yr)
(State, Territory or Foreign Country)
9a. NAME OF INFORMANT
9b. RELATIONSHIP TO FETUS
10. CAUSES/CONDITIONS CONTRIBUTING TO FETAL DEATH
10a. INITIATING CAUSE/CONDITION (Among the choices below, select the ONE
10b. OTHER SIGNIFICANT CAUSES OR CONDITIONS
which most likely began the sequence of events resulting in the death of the fetus)
(Select or specify all other conditions contributing to death in item 10b)
MATERNAL CONDITIONS/DISEASES (Specify):
MATERNAL CONDITIONS/DISEASES (Specify):
COMPLICATIONS OF PLACENTA, CORD OR MEMBRANES:
COMPLICATIONS OF PLACENTA, CORD OR MEMBRANES:
RUPTURE OF MEMBRANES PRIOR TO ONSET OF LABOR
RUPTURE OF MEMBRANES PRIOR TO ONSET OF LABOR
ABRUPTIO PLACENTA
ABRUPTIO PLACENTA
PLACENTAL INSUFFICIENCY
PLACENTAL INSUFFICIENCY
PROLAPSED CORD
PROLAPSED CORD
CHORIOAMNIONITIS
CHORIOAMNIONITIS
OTHER (Specify):
OTHER (Specify):
OTHER OBSTETRICAL OR PREGNANCY COMPLICATIONS (Specify):
OTHER OBSTETRICAL OR PREGNANCY COMPLICATIONS (Specify):
FETAL ANOMALY (Specify):
FETAL ANOMALY (Specify):
FETAL INJURY (Specify):
FETAL INJURY (Specify):
FETAL INFECTION (Specify):
FETAL INFECTION (Specify):
OTHER FETAL CONDITIONS/DISORDERS (Specify):
OTHER FETAL CONDITIONS/DISORDERS (Specify):
UNKNOWN
UNKNOWN
10c. WEIGHT OF FETUS
10d. OBSTRETRIC ESTIMATE OF
grams
lb/oz
(completed weeks)
(grams preferred, specify unit)/oz
GESTATION AT DELIVERY
10e. ESTIMATED TIME OF
DEAD AT TIME OF FIRST ASSESSMENT, NO LABOR ONGOING
DIED DURING LABOR, AFTER FIRST ASSESSMENT
FETAL DEATH
DEAD AT TIME OF FIRST ASSESSMENT, LABOR ONGOING
UNKNOWN TIME OF FETAL DEATH
10f. WAS AN
10g. WAS A HISTOLOGICAL
10h. WERE AUTOPSY OR HISTOLOGICAL
YES
YES
YES
AUTOPSY
PLACENTAL EXAMINATION
PLACENTAL EXAMINATION RESULTS USED IN
NO
NO
NO
PERFORMED?
PERFORMED?
DETERMINING THE CAUSE OF FETAL DEATH?
PLANNED
PLANNED
11a. NAME OF CERTIFIER/ATTENDANT
11b. NPI
11c. TITLE
ATTENDING
MD /
DO
11d. ADDRESS OF CERTIFIER/ATTENDANT
MEDICAL EXAMINER
CERTIFYING
MD /
DO
11e. SIGNATURE OF CERTIFIER/ATTENDANT
11f. DATE
12a. NAME OF PERSON COMPLETING REPORT
12b. TITLE
12c. DATE REPORT COMPLETED
(MM/DD/YYYY)
13. DISPOSITION
BURIAL
CREMATION
HOSPITAL DISPOSITION
DONATION
REMOVAL FROM STATE
OTHER
):
(Specify
14. NAME OF CEMETERY OR CREMATORY
15a. CITY/TOWN
15b. STATE
16. NAME AND ADDRESS OF FUNERAL HOME
17a. NAME OF FUNERAL DIRECTOR (Print or Type)
17b. SIGNATURE OF FUNERAL DIRECTOR
17c. NJ LICENSE NO.
18a. NAME OF REGISTRAR (Print or Type)
18b. SIGNATURE OF REGISTRAR
18c. DATE RECEIVED BY REGISTRAR
(MM/DD/YYYY
REG-26
STATE FILE NO.
New Jersey Department of Health
JUL 18
CERTIFICATE OF FETAL DEATH
1. NAME OF FETUS (First, Middle, Last) (OPTIONAL)
2a. DATE OF DELIVERY (Mo/Day/Yr)
2b. TIME (24 Hour)
3. SEX
4a. THIS DELIVERY
4b. IF NOT SINGLE DELIVERY, THIS FETUS DELIVERED
MALE
FEMALE
________
________
SINGLE
TWIN
OTHER
1st
2nd
OTHER
UNKNOWN/UNDETERMINED
(Specify)
(Specify)
5a. PLACE OF DELIVERY
1
HOSPITAL
3
CLINIC/DOCTOR’S OFFICE
5
OTHER (Specify):
2
FREESTANDING BIRTHING CENTER
4
HOME DELIVERY-Planned to deliver at home?
Yes
No
5b. NAME OF FACILITY (If not institution, give street address)
5c. FACILITY ID (NPI)
5d. CITY, TOWN OR LOCATION OF DELIVERY
5e. COUNTY OF DELIVERY
5f. ZIP CODE OF DELIVERY
6a. MOTHER’S CURRENT LEGAL NAME (First, Middle, Last, Suffix)
6b. DATE OF BIRTH
(Mo/Day/Yr)
6c. MOTHER’S NAME PRIOR TO FIRST MARRIAGE (List name given at birth or on birth certificate/Maiden
6d. BIRTHPLACE
(State, Territory or Foreign Country)
name)(First, Middle, Last, Suffix)
7a. RESIDENCE OF MOTHER - STATE
7b. COUNTY
7c. CITY OR TOWN
7d. STREET AND NUMBER
7e. APT NO.
7f. ZIP CODE
7g. INSIDE CITY LIMITS
(or Mother’s Mailing Address, if different from 7d)
YES
NO
8a. FATHER’S CURRENT LEGAL NAME (First, Middle, Last, Suffix)
8b. DATE OF BIRTH
8c. BIRTHPLACE
(Mo/Day/Yr)
(State, Territory or Foreign Country)
9a. NAME OF INFORMANT
9b. RELATIONSHIP TO FETUS
10. CAUSES/CONDITIONS CONTRIBUTING TO FETAL DEATH
10a. INITIATING CAUSE/CONDITION (Among the choices below, select the ONE
10b. OTHER SIGNIFICANT CAUSES OR CONDITIONS
which most likely began the sequence of events resulting in the death of the fetus)
(Select or specify all other conditions contributing to death in item 10b)
MATERNAL CONDITIONS/DISEASES (Specify):
MATERNAL CONDITIONS/DISEASES (Specify):
COMPLICATIONS OF PLACENTA, CORD OR MEMBRANES:
COMPLICATIONS OF PLACENTA, CORD OR MEMBRANES:
RUPTURE OF MEMBRANES PRIOR TO ONSET OF LABOR
RUPTURE OF MEMBRANES PRIOR TO ONSET OF LABOR
ABRUPTIO PLACENTA
ABRUPTIO PLACENTA
PLACENTAL INSUFFICIENCY
PLACENTAL INSUFFICIENCY
PROLAPSED CORD
PROLAPSED CORD
CHORIOAMNIONITIS
CHORIOAMNIONITIS
OTHER (Specify):
OTHER (Specify):
OTHER OBSTETRICAL OR PREGNANCY COMPLICATIONS (Specify):
OTHER OBSTETRICAL OR PREGNANCY COMPLICATIONS (Specify):
FETAL ANOMALY (Specify):
FETAL ANOMALY (Specify):
FETAL INJURY (Specify):
FETAL INJURY (Specify):
FETAL INFECTION (Specify):
FETAL INFECTION (Specify):
OTHER FETAL CONDITIONS/DISORDERS (Specify):
OTHER FETAL CONDITIONS/DISORDERS (Specify):
UNKNOWN
UNKNOWN
10c. WEIGHT OF FETUS
10d. OBSTRETRIC ESTIMATE OF
grams
lb/oz
(completed weeks)
(grams preferred, specify unit)/oz
GESTATION AT DELIVERY
10e. ESTIMATED TIME OF
DEAD AT TIME OF FIRST ASSESSMENT, NO LABOR ONGOING
DIED DURING LABOR, AFTER FIRST ASSESSMENT
FETAL DEATH
DEAD AT TIME OF FIRST ASSESSMENT, LABOR ONGOING
UNKNOWN TIME OF FETAL DEATH
10f. WAS AN
10g. WAS A HISTOLOGICAL
10h. WERE AUTOPSY OR HISTOLOGICAL
YES
YES
YES
AUTOPSY
PLACENTAL EXAMINATION
PLACENTAL EXAMINATION RESULTS USED IN
NO
NO
NO
PERFORMED?
PERFORMED?
DETERMINING THE CAUSE OF FETAL DEATH?
PLANNED
PLANNED
11a. NAME OF CERTIFIER/ATTENDANT
11b. NPI
11c. TITLE
ATTENDING
MD /
DO
11d. ADDRESS OF CERTIFIER/ATTENDANT
MEDICAL EXAMINER
CERTIFYING
MD /
DO
11e. SIGNATURE OF CERTIFIER/ATTENDANT
11f. DATE
12a. NAME OF PERSON COMPLETING REPORT
12b. TITLE
12c. DATE REPORT COMPLETED
(MM/DD/YYYY)
13. DISPOSITION
BURIAL
CREMATION
HOSPITAL DISPOSITION
DONATION
REMOVAL FROM STATE
OTHER
):
(Specify
14. NAME OF CEMETERY OR CREMATORY
15a. CITY/TOWN
15b. STATE
16. NAME AND ADDRESS OF FUNERAL HOME
17a. NAME OF FUNERAL DIRECTOR (Print or Type)
17b. SIGNATURE OF FUNERAL DIRECTOR
17c. NJ LICENSE NO.
18a. NAME OF REGISTRAR (Print or Type)
18b. SIGNATURE OF REGISTRAR
18c. DATE RECEIVED BY REGISTRAR
(MM/DD/YYYY
STATE FILE NO.
New Jersey Department of Health
CERTIFICATE OF FETAL DEATH
THE FOLLOWING CONFIDENTIAL INFORMATION MAY BE USED IN CONNECTION WITH RESEARCH STUDIES APPROVED BY THE PUBLIC HEALTH
COUNCIL AS AUTHORIZED BY CHAPTER 68, P.L. 1963. SUCH INFORMATION WILL NOT APPEAR ON ANY CERTIFIED COPY OF THIS RECORD.
19a. MOTHER’S EDUCATION (Check the box
20a. MOTHER’S HISPANIC ORIGIN
21a. MOTHER’S RACE (Check one or more races to indicate what the mother
that best describes the highest degree or
(Check the box that best describes
considers herself to be.)
level of school completed at the time of
whether the mother is
White
delivery.)
Spanish/Hispanic/Latina. Check the
Black or African American
“No” box if mother is not
8th grade or less
American Indian or Alaska Native
Spanish/Hispanic/Latina.)
_________________
9th-12th grade, no diploma
(Name of enrolled or principal tribe):
No, not
Asian Indian
High school graduate or GED
Spanish/Hispanic/Latina
Chinese
completed
Yes, Mexican, Mexican
Filipina
Some college credit but no degree
Japanese
American, Chicana
Associate degree (e.g., AA, AS)
Korean
Yes, Puerto Rican
Bachelor’s degree (e.g., BA, AB,
Vietnamese
Yes, Cuban
BS)
___________
Other Asian (Specify):
Master’s degree (e.g., MA, MS,
Yes, other
Native Hawaiian
Spanish/Hispanic/Latina
MEng, MEd, MSW, MBA)
Guamanian or Chamorro
(Specify):
Samoan
Doctorate (e.g., PhD, EdD) or
___________
Professional degree (e.g. MD.
Other Pacific Islander (Specify):
___________________
DDS, DVM, LLB, JD)
___________
Other (Specify):
19b. FATHER’S EDUCATION (Check the box
20b. FATHER’S HISPANIC ORIGIN
21b. FATHER’S RACE (Check one or more races to indicate what the father
that best describes the highest degree or
(Check the box that best describes
considers himself to be.)
level of school completed at the time of
whether the father is
White
delivery.)
Spanish/Hispanic/Latino. Check the
Black or African American
“No” box if father is not
8th grade or less
American Indian or Alaska Native
Spanish/Hispanic/Latino.)
_________________
9th-12th grade, no diploma
(Name of enrolled or principal tribe):
No, not
Asian Indian
High school graduate or GED
Spanish/Hispanic/Latino
Chinese
completed
Yes, Mexican, Mexican
Filipino
Some college credit but no degree
Japanese
American, Chicano
Associate degree (e.g., AA, AS)
Korean
Yes, Puerto Rican
Bachelor’s degree (e.g., BA, AB,
Vietnamese
Yes, Cuban
BS)
___________
Other Asian (Specify):
Master’s degree (e.g., MA, MS,
Yes, other
Native Hawaiian
Spanish/Hispanic/Latino
MEng, MEd, MSW, MBA)
Guamanian or Chamorro
(Specify):
Samoan
Doctorate (e.g., PhD, EdD) or
___________
Professional degree (e.g. MD.
Other Pacific Islander (Specify):
___________________
DDS, DVM, LLB, JD)
___________
Other (Specify):
22. OCCUPATION DURING THE PAST YEAR
23. BUSINESS/INDUSTRY WORKED AT DURING THE PAST YEAR
a. Mother:
a. Mother:
b. Father:
b. Father:
24. MOTHER MARRIED? (At
25. DATE LAST NORMAL
26. DATE OF FIRST
27. DATE OF LAST PRENATAL CARE
28. TOTAL NUMBER OF
delivery, conception, or
MENSES BEGAN
PRENATAL CARE VISIT
VISIT
PRENATAL VISITS FOR
(MM/DD/YYYY)
any time between)
(MM/DD/YYYY)
(MM/DD/YYYY)
THIS PREGNANCY
_____/_____/_____
(If “None”, enter “0”)
Yes
No
_____/_____/_____
_____/_____/_____
Month / Day / Year
Month / Day / Year
Month / Day / Year
No Prenatal Care
29a. NUMBER OF
29a. NUMBER OF
29c. DATE OF LAST LIVE
30a. NUMBER OF OTHER PREGNANCY
30b. DATE OF LAST OTHER
PREVIOUS LIVE
PREVIOUS LIVE
BIRTH
(MM/YYYY)
OUTCOMES (spontaneous or induced
PREGNANCY
BIRTHS, NOW LIVING
BIRTHS, NOW DEAD
losses or ectopic pregnancies) (Do not
OUTCOME
(MM/YYYY)
_____/_____
include this fetus)
________
_____
Number:
Number:
_____/_____
Month / Year
________
None
Number:
None
None
Month / Year
31. MOTHER’S HEIGHT
32. MOTHER’S PRE-PREGNANCY
33. MOTHER’S WEIGHT AT
34. DID MOTHER GET WIC FOOD FOR HERSELF DURING THIS
(feet/inches)
WEIGHT (pounds)
DELIVERY (pounds)
PREGNANCY?
Yes
No
________
________
________
35a. CIGARETTE SMOKING BEFORE AND DURING PREGNANCY (FOR EACH TIME PERIOD, ENTER EITHER THE AVERAGE NUMBER OF CIGARETTES OR THE
AVERAGE NUMBER OF PACKS OF CIGARETTES SMOKED PER DAY.) IF NONE, ENTER “0”.
________
________
OR
Three Months Before Pregnancy:
number of cigarettes
number of packs
________
________
OR
First Three Months of Pregnancy:
number of cigarettes
number of packs
________
________
OR
Second Three Months of Pregnancy:
number of cigarettes
number of packs
________
________
OR
Third Trimester of Pregnancy:
number of cigarettes
number of packs
35b. OTHER RISK FACTORS FOR THIS PREGNANCY (Complete all items)
________
Alcohol Use during pregnancy?
Yes
No
Average number of drinks per week:
Homelessness?
Yes
No
Domestic Violence?
Yes
No
Use of cocaine, heroin, marijuana, or methamphetamines during pregnancy?
Yes
No
NAME OF FETUS (First, Middle, Last)
REG-26
JUL 18
Page 2 of 3 Pages.
STATE FILE NO.
New Jersey Department of Health
CERTIFICATE OF FETAL DEATH
36a. MOTHER TRANSFERRED FOR MATERNAL MEDICAL OR FETAL INDICATIONS FOR DELIVERY?
No
Yes
IF YES, ENTER NAME OF FACILITY MOTHER TRANSFERRED FROM:
36b. MUNICIPALITY NAME
36c. COUNTY NAME
MEDICAL AND HEALTH INFORMATION
37. MEDICAL RISK FACTORS FOR THIS
40. MATERNAL MORBIDITY
42. CONGENITAL ANOMALIES OF FETUS
PREGNANCY (Check all that apply)
(COMPLICATIONS OF LABOR AND/OR
(PRESENT OR KNOWN TO EXIST)
DELIVERY)
(Check all that apply)
Anemia (Hct. <30 / Hgb. <10)
(Check all that apply)
Cardiac disease
Anencephaly
Febrile (>100° F. or 38° C.)
Acute or chronic lung disease
Meningomyelocele/Spina bifida
Meconium, moderate/heavy
Diabetes, Prepregnancy (diagnosis prior to
Hydrocephalus
Premature rupture of membrane (>12
this pregnancy)
Microcephalus
hours)
Diabetes, Gestational (diagnosis in this
Other CNS anomalies
Abruptio placenta
pregnancy)
________________
(Specify):
Placenta previa
Genital herpes
Heart malformations
Other excessive bleeding
Hydramnios/Oligohydramnios
Cyanotic congenital heart disease
Hemoglobinopathy
Seizures during labor
Congenital diaphragmatic hernia
Precipitous labor (<3 hours)
Hypertension, Prepregnancy (Chronic)
Other circulatory/respiratories
Prolonged labor (>20 hours)
Hypertension, Gestational (PIH,
anomalies
preeclampsia)
Dysfunctional labor
________________
(Specify):
Hypertension, Eclampsia
Breech/Malpresentation
Omphalocele
Incompetent cervix
Cephalopelvic disproportion
Gastroschisis
Previous infant 4000+ grams
Cord prolapse
Rectal atresia / stenosis
Previous preterm birth
Anesthetic complications
Tracheo-esophageal fistula /
Other previous poor pregnancy outcome
Fetal distress
Esophageal atresia
(includes perinatal death, small-for-
Maternal transfusion
Other gastrointestinal anomalies
gestational age/intrauterine growth-
Third or fourth degree perineal laceration
________________
(Specify):
restricted birth)
Ruptured uterus
Malformed genitalia
Renal Disease
Unplanned hysterectomy
Renal agenesis
Rh sensitization
Admission to intensive care unit
Other urogenital anomalies
Uterine bleeding
Unplanned operating room procedure
Pregnancy resulted from infertility
________________
(Specify):
following delivery
treatment; if Yes, check all that apply:
Polydactyly / Syndactyly / Adactyly
________________
Other (Specify):
Fertility-enhancing drugs, artificial
Club foot
None of the above
insemination or intrauterine
Limb reduction defect (excluding
insemination
41. METHOD OF DELIVERY (Check all that
congenital amputation and dwarfing
Assisted reproductive technology [e.g.,
apply)
syndromes)
in vitro fertilization (IVF), gamete
Other musculoskeletal / integumental
A. Was delivery with forceps attempted but
intrafallopian transfer (GIFT)]
anomalies
unsuccessful?
Mother had a previous cesarean delivery;
________________
Yes
No
(Specify):
________
if Yes, how many?
B. Was delivery with vacuum extraction
Cleft Lip with or without Cleft Palate
____________
Other (Specify):
attempted but unsuccessful?
Cleft Palate alone
None of the above
Yes
No
Down Syndrome
Karyotype confirmed
38. INFECTIONS PRESENT AND/OR TREATED
C. Fetal presentation at delivery:
DURING THIS PREGNANCY (Check all that
Karyotype pending
Cephalic
apply)
Suspected chromosomal disorder
Breech
Karyotype confirmed
Gonorrhea
Other
Karyotype pending
Syphilis
D. Final route and method of delivery
Other chromosomal anomalies
Chlamydia
(Check one)
________________
Listeria
(Specify):
D&E
Group B Streptococcus
Hypospadias
Vaginal/Spontaneous
Cytomegalovirus
Other
Vaginal/Forceps
Parvovirus
________________
(Specify):
Vaginal/Vacuum
Toxoplasmosis
None of the anomalies listed above
If vaginal, was vaginal birth after
None of the above
previous Cesarean section?
________________
Other (Specify):
Yes
No
Cesarean, Primary
39. OBSTETRIC PROCEDURES
Cesarean, Repeat
(Check all that apply)
If cesarean, was a trial of labor
None
attempted?
Amniocentesis
Yes
No
Electronic fetal monitoring
E. Hysterotomy/Hysterectomy
Induction of labor
Yes
No
Stimulation of labor
Tocolysis
Ultrasound
____________
Other (Specify):
NAME OF FETUS (First, Middle, Last)
REG-26
JUL 18
Page 3 of 3 Pages.
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