MANDATORY REPORT OF A MATERNAL DEATH
Michigan Department of Health and Human Services
Please send this report immediately after the death of a woman who was currently pregnant or was pregnant with 365 days of death. Report the event regardless of where the patient died. Please provide as much detail as possible, and submit any associated medical records (e.g., discharge summaries, autopsy reports, EMS reports, etc.) along with this reporting form.
1.	Name of woman
Last	First	Middle	Maiden
Address
Street	City	State	Zip
2.	Date of death
2.	Time of death
3.	Date of birth
4.	Woman’s Social Security Number
5.	Pregnancy Status:
Pregnant at Death	Estimated Gestation
Live birth in past year
Miscarriage/Stillbirth in past year
Date of delivery
Name of birth hospital (if known)
Name of Obstetrician (if known)
Names of other hospitals woman was admitted to during the past year
6.	Location of death
7.	Hospital of death
City
If different from 5. above
8.	Woman’s medical record number
9.	Name of attending physician at death
10.	Autopsy
None
Yes – at site of death
Yes – at other site
11.	Cause of death
12.	Name of medical examiner or hospital pathologist
13.	Name of facility or address where autopsy was performed
14.	Report prepared by
Date
15.	Name of organization
Telephone
PLEASE RETURN THIS FORM AND THE ASSOCIATED MEDICAL RECORDS BY STANDARD MAIL TO:

Maternal Mortality Surveillance

Bureau of Epidemiology and Population Health

Michigan Department of Health and Human Services

South Grand Building

333 South Grand Ave, 2nd Floor

Lansing, MI 48933

OR BY EMAIL TO: MDHHS-MaternalMortality@michigan.gov

DCH-1341 (Rev. 5-17) Previous edition obsolete.	1	Confidentiality assured by MCL 333.2631

By authority Act 479, P.A. 2016

Mandatory Report of a Maternal Death

Bureau of Epidemiology and Population Health

2017-03-10

Vallejo, Delia (DHHS)

Michigan Department of Health and Human Services