Form Mo 886 3228 PDF Details

In the challenging and painful circumstances of a child's sudden or unexplained death, the role of precise and compassionate investigation cannot be overstated. The MO 886 3228 form, issued by the Missouri Department of Social Services under its Missouri Child Fatality Review Program, serves as a cornerstone in guiding officials through the meticulous process of scene investigation. Designed with a focus on children fatalities, especially those under the age of one, this checklist not only ensures a thorough investigation but also aids pathologists in understanding the cause and manner of death. The form encapsulates a comprehensive approach, starting from collecting basic victim identifiers and pre-natal history to scrutinizing the conditions surrounding the death. It prompts the investigator to pay close attention to the scene, recreate events, and meticulously document findings related to the child’s health, sleeping conditions, and potential signs of distress or neglect. The emphasis on collecting evidence without presumption of criminality, while keeping an open mind to all possibilities, reflects the dual focus on empathy and diligence. Furthermore, the inclusion of details like environmental conditions and social background offers a holistic view of the circumstances, enabling a nuanced understanding of each tragedy. By facilitating a systematic collection of sensitive information, the MO 886 3228 form embodies the critical balance between investigatory thoroughness and the profound respect owed to the young lives lost and their bereaved families.

QuestionAnswer
Form NameForm Mo 886 3228
Form Length4 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min
Other namescriminality, death investigation checklist, investigation for dog report death, child death investigation checklist

Form Preview Example

STAT

MISSOURI DEPARTMENT OF SOCIAL SERVICES MISSOURI CHILD FATALITY REVIEW PROGRAM

PO BOX 208

JEFFERSON CITY, MO 65102-0208 (573) 751-5980

DEATH SCENE INVESTIGATIVE CHECKLIST FOR CHILD FATALITIES

(800) 487-1626

INSTRUCTIONS

When a child dies suddenly and unexpectedly, or suspiciously, a thorough evaluation/investigation of the scene is necessary to accurately determine the cause and manner of death. The scene investigation should happen as soon as possible after the child’s death, optimally within 24 hours.

This checklist should be used as a guide to your investigation of the scene of a sudden and unexplained or suspicious death, especially to a child under the age of one. Completing all information appropriate to the fatality will help the pathologist determine how and why the child died. For assistance, call (800) 487- 1626.

The questions in the checklist will lead you through a thorough investigation. It is not expected that you will be able to answer all of the questions. You should attempt to interview witnesses, EMS and emergency room personnel, child care providers, law enforcement, and other persons from the scene.

In conducting the investigation, criminality or negligence should not be assumed, but the possibility should not be overlooked. An empathetic, non- confrontational approach is both appropriate and effective.

Complete as many sections as possible. If appropriate, attach this form to your investigation report. Submit a copy to the Medical Examiner’s Office prior to the autopsy.

Because the child will probably have already been transported to a hospital or other facility, it is important that, based on evidence and witness accounts, you try to recreate the scene to approximate actual events. This may include the use of dolls or silhouettes to reconstruct location and position of body. Attempt to acquire scene and reconstruction photographs as appropriate.

Contact your Prosecuting Attorney’s Office to ensure that all laws and regulations are followed in the search of the area, the interviewing of witnesses, and the collection of evidence. Only use procedures and forms approved by your agency and prosecutor. Sample forms are available from STAT.

VICTIM IDENTIFIERS AND PRE-NATAL HISTORY

1. CHILD’S NAME

 

 

2. SOCIAL SECURITY NUMBER

 

 

 

 

 

3. SCENE ADDRESS

 

 

 

 

 

 

 

 

 

4. DATE OF BIRTH

5. DATE OF DEATH

6. RACE OF CHILD

 

7. SEX

 

 

 

 

 

8. DECEDENT’S ADDRESS

9. MOTHER’S NAME

10. MOTHER’S ADDRESS

11. MOTHER’S TELEPHONE NUMBER

 

 

12. MOTHER’S DATE OF BIRTH

 

 

13. MOTHER’S SOCIAL SECURITY NUMBER

 

 

 

 

 

 

14. GESTATION IN WEEKS

15. BIRTH WEIGHT

 

16. KNOWN MATERNAL PRE-NATAL HEALTH PROBLEMS (DIABETES, HYPERTENSION, ETC.)?

 

 

 

 

NO

YES

UNKNOWN

 

 

 

 

 

 

 

 

IF YES, DESCRIBE

17. WAS MOTHER TAKING PRESCRIPTION MEDICATION FOR ABOVE MEDICAL CONDITION DURING PREGNANCY?

NO

YES

UNKNOWN If yes, what type of medication?

18. PRE-NATAL MATERNAL CIGARETTE, ALCOHOL OR DRUG USAGE?

IF YES,

 

 

 

 

 

 

NO

YES

UNKNOWN

Alcohol

Cigarettes

Cocaine

Heroin

Marijuana

Methamphetamine

Other

 

 

 

 

 

 

 

 

 

 

19. KNOWN COMPLICATIONS OF PREGNANCY OR DELIVERY?

NO

YES

UNKNOWN If yes, explain:

20.LOCATION OF BIRTH AND NAME OF FACILITY

21.ATTENDING MEDICAL PRACTITIONER

22.BIRTH DEFECTS OR OTHER ABNORMALITIES OF DECEDENT AT BIRTH, DESCRIBE:

MO 886-3228 (11-06)

23. ANY FAMILY HISTORY OF SIDS OR OTHER INFANT DEATH?

NO

YES

UNKNOWN

IF YES, DESCRIBE DETAILS INCLUDING DATE OF DEATH AND LOCATION OF OCCURRENCE:

EVENTS SURROUNDING DEATH

24. PLACE OF FATAL EVENT (E.G., IN CRIB, IN CAR)?

 

25. DEATH WITNESSED?

 

 

 

 

 

NO

YES

If yes, provide detail in narrative.

 

 

 

 

 

 

26. WHO FOUND CHILD?

 

 

TIME FOUND

 

 

 

 

 

 

27. STATUS OF CHILD WHEN FOUND

 

 

28. WHEN WAS CHILD LAST SEEN ALIVE (TIME, WHERE, BY WHOM)?

Dead

Unresponsive

In Distress

Unsure

 

 

 

 

 

 

 

 

 

 

29. DESCRIBE CONDITION OF CHILD WHEN LAST SEEN:

30. MEDICAL ASSISTANCE SUMMONED?

NO

YES

31. 911 CALL?

 

NO

YES If yes, obtain tapes.

32. RESUSCITATION ATTEMPTED?

 

BY WHOM?

 

 

HISTORY OF PREVIOUS RESUSCITATION?

NO

YES

 

 

 

 

NO

YES

UNKNOWN

 

 

 

 

 

 

 

 

 

33. CONVEYED TO A MEDICAL FACILITY?

 

WHERE?

 

 

NAME AND ADDRESS OF FACILITY

 

NO

YES

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

34. WHO PRONOUNCED CHILD DEAD?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CONDITION OF CHILD

 

 

 

 

 

 

 

35. BODY TEMPERATURE (DEGREES)

 

TIME

 

METHOD

 

 

SWEATY?

 

 

 

 

 

 

 

 

 

NO

YES

 

 

 

 

 

 

 

 

36. LIVOR MORTIS

 

 

TIME

 

WHERE OBSERVED?

CONSISTENT WITH POSITION WHEN FOUND?

NO

YES

 

 

 

 

 

 

NO

YES (See Question 44)

 

 

 

 

 

 

 

 

 

37. RIGOR MORTIS

 

 

TIME

 

38. HEMORRHAGE OF EYES, LIPS OR EARS?

 

 

NO

YES

 

 

 

NO

YES

 

 

 

 

 

 

 

 

 

 

39. CHILD APPEARS CLEAN, WELL NOURISHED AND CARED FOR

 

 

 

 

 

NO

YES If no, explain in narrative.

 

 

 

 

 

 

 

 

 

 

 

 

 

40. CLOTHING CLEAN?

 

RIGHT SIZE?

 

CLOTHING REMOVED AFTER DEATH?

CLOTHING TYPE

 

NO

YES

 

NO

YES

NO

YES

 

 

 

 

 

 

 

 

 

 

 

41. DIAPERS USED? (COLLECT AS NECESSARY)

 

 

WET?

 

 

SOILED?

 

NO

YES

 

 

NO

YES

NO

YES

 

 

 

 

 

 

 

 

 

 

42. ARE THERE BIRTHMARKS OR INJURIES OF ANY TYPE, INCLUDING BRUISES, SCRAPES, CUTS, BURNS OR DIAPER RASH?

NO

YES If yes, describe colors, shapes, sizes and locations in narrative. Ensure that necessary photos are taken if possible.

POSITION OF CHILD

43. SKETCH POSITION OF CHILD AND IDENTIFY WHERE IN CRIB, BED, OR OTHER PLACE

IF BABY IS NOT PRESENT, ENSURE THAT PHOTOS ARE TAKEN OF POSITIONED DOLL OR SILHOUETTE.

INDICATE DIRECTION OF CHILD’S HEAD (CHECK ONE):

N

W

E

S

44. WAS CHILD MOVED FROM ORIGINAL POSITION?

NO

YES

WHY?

MO 886-3228 (11-06)

45. POSITION WHEN DISCOVERED (REFER BACK TO QUESTION 43):

 

 

 

 

 

 

 

 

 

BODY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

On Stomach

On Back

Seated Upright

Left Side

Right Side

 

 

 

 

BODY PINNED

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Pinned Vertically

 

Pinned Horizontally

Other Wedging

Not Pinned

 

 

 

 

HEAD AND NECK

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Face Directly Up

 

Face Directly Down

Face to Right

Face to Left

 

Neck Flexed to Chin

Neck Extended Back

USUAL SLEEPING POSITION

 

 

 

 

 

 

 

 

 

 

 

 

 

On Stomach

On Back

Seated Upright

Left Side

Right Side

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

46. WAS AIRWAY OBSTRUCTED WHEN DISCOVERED?

 

 

 

 

 

 

 

 

 

Airway Not Obstructed

 

Right Nostril Blocked

Object Covering Mouth

 

Objects Near Face

Both Nostrils Blocked

 

Left Nostril Blocked

Object Covering Nose

 

 

 

 

 

 

 

 

 

 

 

 

 

47. DESCRIBE ANY OBJECTS COVERING NOSE, MOUTH OR FACE:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

48. IF CHILD WAS FOUND FACE DOWN, IS THERE A VISIBLE CUP, POCKET OR DEPRESSION IN THE BEDDING?

 

 

 

 

 

NO

YES

Depth:

 

 

Diameter:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

49. IS THERE A VISIBLE CREASE ON FACE, NECK OR HANDS FROM PILLOWS OR BEDDING?

 

 

 

 

 

 

NO

YES

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

50. MATERIAL FOUND IN NOSE OR MOUTH:

 

 

 

 

 

 

 

 

 

 

 

None

 

 

Formula

 

 

 

Bloody Froth

 

Blood Tinged Secretion

 

Mucous

 

 

Vomit

 

 

 

Dried Secretion

 

Other

 

 

 

 

Food

 

 

Froth

 

 

 

Urine or Stool

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

51. SECRETION FOUND ON:

 

 

 

 

 

 

 

 

 

 

 

 

 

Blanket

 

 

Sheet

 

 

 

Clothing

 

Pillow

 

 

 

Other Item

 

 

 

 

 

 

 

 

 

 

 

 

 

52. WHAT TYPE OF SECRETION

 

 

 

 

 

 

 

 

 

 

 

 

None

 

 

Formula

 

 

 

Bloody Froth

 

Blood Tinged Secretion

 

Mucous

 

 

Vomit

 

 

 

Dried Secretion

 

Other Secretion

 

 

Food

 

 

Froth

 

 

 

Urine or Stool

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

53. FACE IN CONTACT WITH WET MATERIALS

 

 

 

 

DESCRIBE:

 

 

 

 

 

NO

YES

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

54. IF FOUND WHILE SLEEPING, WAS CHILD SLEEPING ALONE?

 

 

 

 

 

 

 

 

 

NO

YES

If no, who was child sleeping with?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

55. DESCRIBE BED AND/OR OTHER SLEEPING SURFACE.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

56. LIST ALL MATERIALS AND OBJECTS NEAR CHILD WHEN FOUND, INCLUDING BED, SHEETS, PILLOWS, COVERS, TOYS, HOUSEHOLD OBJECTS, ETC.

 

 

 

 

 

 

 

 

 

 

 

57. COULD ANY OF THESE MATERIALS AND OBJECTS HAVE INFLUENCED THE DEATH?

 

 

 

 

 

 

NO

Yes

If yes, describe in narrative.

 

 

 

 

 

 

 

 

 

 

 

 

 

58. IS THERE ANY POSSIBILITY OF OVERLYING? FOR EXAMPLE, TOO LITTLE ROOM FOR TOO MANY PEOPLE, RECENT ALCOHOL OR OTHER DRUG CONSUMPTION BY PERSON SLEEPING WITH CHILD.

NO

YES

If yes, explain in narrative.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

59. IS THERE AN APNEA MONITOR IN THE HOME?

 

 

 

 

WAS CHILD ON MONITOR AT TIME OF DEATH?

 

 

NO

YES

Download information from monitor.

 

NO

YES

 

Collect monitor as evidence.

 

 

 

 

 

 

 

 

 

 

 

SOCIAL AND ENVIRONMENTAL CONDITIONS

 

 

 

 

 

 

 

 

 

60. WHO DOES CHILD LIVE WITH?

 

 

 

 

 

61. WHO HAD RESPONSIBILITY FOR CHILD AT TIME OF DEATH? IN NARRATIVE, DESCRIBE

 

 

 

 

 

 

 

 

ACTIVITIES OF CAREGIVERS DURING DAYS LEADING UP TO THE DEATH.

 

 

 

 

 

 

 

62. HAVE FAMILY MEMBERS OR CARETAKERS BEEN REPORTED FOR PAST ABUSE OR NEGLECT?

 

 

 

FOR DOMESTIC VIOLENCE?

NO

YES

Contact Hotline to obtain information. (800-392-3738)

 

 

NO

YES

 

 

 

 

 

 

 

 

 

 

 

 

63. LIST CHILD CARE PROVIDERS - LICENSED

 

 

 

 

UNLICENSED

 

 

 

 

 

 

 

 

 

 

 

 

64. DO SIBLINGS EVER WATCH CHILD UNATTENDED?

 

 

 

 

65. ARE THERE ANY CULTURAL PRACTICES THAT MAY HAVE INFLUENCED THE DEATH?

NO

YES

If yes, age:

 

 

 

 

 

NO

YES

 

If yes, explain fully in the narrative.

 

 

 

 

 

 

 

 

 

 

 

 

 

66. DESCRIPTION OF DWELLING:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

67. CLEANLINESS OF DWELLING

 

 

 

 

 

 

 

 

 

 

 

 

BELOW AVERAGE

ABOVE AVERAGE

 

AVERAGE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

68. NUMBER OF CHILDREN LIVING AT ADDRESS

 

NUMBER OF ADULTS

 

 

 

OVERCROWDED?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NO

YES

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MO 886-3228 (11-06)

69. ARE THERE ANY ENVIRONMENTAL HAZARDS?

 

 

 

 

 

 

 

 

NO

YES

If yes, check all that apply.

 

 

 

 

 

 

 

 

Tobacco Smoke

High Room Temp

Recent Remodeling

Tobacco

 

Animals

 

Drugs or Alcohol

Low Room Temp

Toxic Gases

Lead

 

Other

 

Medicines

 

Unusual Dampness

Toxic Products

Electrical

 

 

 

 

 

 

 

 

 

 

 

 

70. ROOM TEMPERATURE

 

OUTSIDE TEMPERATURE

 

HEATING/COOLING SOURCE

 

 

 

PROXIMITY OF CHILD TO HEAT/COOLING SOURCE

 

 

 

 

 

 

 

 

 

 

CHECKLIST FOR DISCRETIONARY COLLECTION OF EVIDENCE

 

 

 

 

 

 

Clothing

 

Medicines

Baby Bottles

 

 

Toys

 

Bedding

 

Drug Paraphernalia

Formula/Food

 

 

Equipment

 

Diapers

 

Folk Remedies

Honey, if fed within 30 days

Other

 

 

 

 

 

 

 

 

 

 

 

 

TRACE EVIDENCE COLLECTED: LIST

 

LOCATION FOUND

 

 

DISPOSITION AND PRESENT LOCATION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PHOTOS TAKEN?

 

 

 

 

 

 

 

 

 

 

 

 

NO

YES

If yes, by whom?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ALL WITNESSES, RESPONDERS, AND OTHER PERSONS AT SCENE

 

 

 

 

 

List all persons at scene during time child died.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NAME

 

ADDRESS

 

 

 

RELATIONSHIP

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NARRATIVE (USE ADDITIONAL PAGES AS NECESSARY)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

71. DATE/TIME OF INVESTIGATION

 

72. CASE NUMBER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

73. INVESTIGATOR’S NAME

 

 

 

 

74. AGENCY/DEPARTMENT

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MO 886-3228 (11-06)