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Objectives: We sought to describe approaches to surveillance of fatal child maltreatment and to identify options for improving case ascertainment., Methods: Three states--California, Michigan, and Rhode Island--used multiple data sources for surveillance. Potential cases were identified, operational definitions were applied, and the number of maltreatment deaths was determined., Results: These programs identified 258 maltreatment deaths in California, 192 in Michigan, and 60 in Rhode Island. Corresponding maltreatment fatality rates ranged from 2.5 per 100,000 population in Michigan to 8.8 in Rhode Island. Most deaths were identified by child death review teams in Rhode Island (98%), Uniform Crime Reports in California (56%), and child welfare agency data in Michigan (44%). Compared with the total number of cases identified, child welfare agency (the official source for maltreatment reports) and death certificate data underascertain child maltreatment deaths by 55% to 76% and 80% to 90%, respectively. In all 3 states, more than 90% of cases ascertained could be identified by combining 2 data sources., Conclusions: No single data source was adequate for thorough surveillance of fatal child maltreatment, but combining just 2 sources substantially increased case ascertainment. The child death review team process may be the most promising surveillance approach.