*1.Date:(Required.)

*2.Review Team:(Required.)

Child Death Review Team

Fetal Infant Mortality Review Team

Wisconsin Child Death Review State Advisory Council

*3.County:(Required.)

AshlandBarronBrownBuffaloBurnettChippewaClarkColumbiaCrawfordDaneDodgeDoorDouglasDunnEau ClaireFlorenceFond du LacForestGreenJacksonJeffersonJuneauKenoshaKewauneeLa CrosseLafayetteLangladeLincolnManitowocMarathonMarinetteMilwaukeeMonroeOcontoOneidaOutagamiePiercePortagePriceRacineRockRuskSaukSawyerShawanoSheboyganSt. CroixTaylorTreampleauVilasWalworthWashbrunWashington OzqukeeWaukeshaWaupacaWausharaWinnebagoWoodNot Applicable

4.Lead Agency:

5.Contact Person:

6.Phone Number:

7.Email:

8.List risk factors that led to the activity, recommendations or outcome.

9.List the activity, recommendations or outcomes that resulted from the team's case reviews.

10.Is this activity, recommendation or outcome data-driven? If so, please describe. (For example, the team reviewed two teen suicides in 6 months). 

11.Is there a policy or practice local or state agencies should review as a result of this cause of death? Please explain.

12.List outcome(s) that have resulted from the implementation of this activity or recommendation.