PROJECT SUMMARY Firearm injury is a leading cause of pediatric morbidity and mortality in the United States (US). In 2018, firearms were attributed to approximately 6,500 pediatric injuries, and 1,700 child deaths. Half of these deaths were related to homicide, and 40% related to suicide. Until recently, funding restrictions have prevented the evolution of research in this important public health area, and much of the extant pediatric firearm literature has been limited to the use of data sources with small sample sizes and limited geographic scope. As a result, research on pediatric firearm injuries and deaths has lagged behind other areas of pediatric health. The recent literature has predominantly used descriptive epidemiology to explain the burden of injuries and deaths at trauma centers. Less is understood about the circumstantial characteristics and racial/ethnic disparities associated with pediatric homicides and suicides involving firearms. The proposed study will address this gap in the literature using data from the 17 states reporting to the National Violent Death Reporting System (NVDRS) from 2014-2018. The NVDRS contains over 600 variables related to decedents, perpetrators, crime scenes, and forensic exams and includes medical examiner and law enforcement narratives. With this data, we propose to examine the familial and circumstantial characteristics (e.g., intimate partner violence, financial stress, health problems, substance misuse, gang activity) of firearm-related deaths of US children, and determine how these factors vary by race/ethnicity using measures of disparity and disproportionality. Additionally, using a mixed methods approach, we will elucidate the circumstances of firearm-related deaths in US children aged 0-17 years by intent (e.g., homicide, suicide, unintentional). Firearm-related deaths will be identified using International Classification of Diseases, 10th Revision (ICD-10), and external cause of injury codes. Cases not captured using ICD-10 and e-codes will be identified using additional variables operationalized within NVDRS (e.g., immediate cause of death, underlying cause of death). Qualitative analysis of medical examiner and law enforcement narratives will identify unique themes and provide context to the relationships characterized using quantitative methods. To assess the generalizability of our results, sensitivity analysis will be used to compare the results from the proposed study of 17 states with the 50 NVDRS states reporting in 2018. The long-term goal of this study is to provide much-needed context to pediatric firearm deaths that can inform future prevention efforts at the levels of research, policy, and practice.