There are a few important things to keep in mind when filing your tax return. One of them is making sure you use the correct form. Form MO 886 3228 is for residents of Missouri who have income from gambling or lottery winnings. If you're not sure which form to use, consult a tax professional. Filing your taxes incorrectly can result in penalties and interest, so it's important to make sure everything is done correctly.
| Question | Answer |
|---|---|
| Form Name | Form Mo 886 3228 |
| Form Length | 4 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 1 min |
| Other names | criminality, death investigation checklist, investigation for dog report death, child death investigation checklist |
STAT
MISSOURI DEPARTMENT OF SOCIAL SERVICES MISSOURI CHILD FATALITY REVIEW PROGRAM
PO BOX 208
JEFFERSON CITY, MO
DEATH SCENE INVESTIGATIVE CHECKLIST FOR CHILD FATALITIES |
(800) |
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
1. CHILD’S NAME |
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2. SOCIAL SECURITY NUMBER |
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3. SCENE ADDRESS |
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4. DATE OF BIRTH |
5. DATE OF DEATH |
6. RACE OF CHILD |
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7. SEX |
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8. DECEDENT’S ADDRESS
9. MOTHER’S NAME
10. MOTHER’S ADDRESS
11. MOTHER’S TELEPHONE NUMBER |
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12. MOTHER’S DATE OF BIRTH |
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13. MOTHER’S SOCIAL SECURITY NUMBER |
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14. GESTATION IN WEEKS |
15. BIRTH WEIGHT |
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16. KNOWN MATERNAL |
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NO |
YES |
UNKNOWN |
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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. |
IF YES, |
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NO |
YES |
UNKNOWN |
Alcohol |
Cigarettes |
Cocaine |
Heroin |
Marijuana |
Methamphetamine |
Other |
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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
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)? |
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25. DEATH WITNESSED? |
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NO |
YES |
If yes, provide detail in narrative. |
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26. WHO FOUND CHILD? |
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TIME FOUND |
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27. STATUS OF CHILD WHEN FOUND |
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28. WHEN WAS CHILD LAST SEEN ALIVE (TIME, WHERE, BY WHOM)? |
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Dead |
Unresponsive |
In Distress |
Unsure |
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29. DESCRIBE CONDITION OF CHILD WHEN LAST SEEN:
30. MEDICAL ASSISTANCE SUMMONED?
NO |
YES |
31. 911 CALL? |
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NO |
YES If yes, obtain tapes. |
32. RESUSCITATION ATTEMPTED? |
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BY WHOM? |
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HISTORY OF PREVIOUS RESUSCITATION? |
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NO |
YES |
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NO |
YES |
UNKNOWN |
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33. CONVEYED TO A MEDICAL FACILITY? |
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WHERE? |
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NAME AND ADDRESS OF FACILITY |
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NO |
YES |
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34. WHO PRONOUNCED CHILD DEAD? |
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CONDITION OF CHILD |
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35. BODY TEMPERATURE (DEGREES) |
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TIME |
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METHOD |
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SWEATY? |
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YES |
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36. LIVOR MORTIS |
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TIME |
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WHERE OBSERVED? |
CONSISTENT WITH POSITION WHEN FOUND? |
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NO |
YES |
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NO |
YES (See Question 44) |
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37. RIGOR MORTIS |
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TIME |
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38. HEMORRHAGE OF EYES, LIPS OR EARS? |
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NO |
YES |
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NO |
YES |
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39. CHILD APPEARS CLEAN, WELL NOURISHED AND CARED FOR |
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NO |
YES If no, explain in narrative. |
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40. CLOTHING CLEAN? |
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RIGHT SIZE? |
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CLOTHING REMOVED AFTER DEATH? |
CLOTHING TYPE |
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NO |
YES |
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YES |
NO |
YES |
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41. DIAPERS USED? (COLLECT AS NECESSARY) |
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WET? |
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SOILED? |
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NO |
YES |
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NO |
YES |
NO |
YES |
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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
45. POSITION WHEN DISCOVERED (REFER BACK TO QUESTION 43): |
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BODY |
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On Stomach |
On Back |
Seated Upright |
Left Side |
Right Side |
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BODY PINNED |
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Pinned Vertically |
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Pinned Horizontally |
Other Wedging |
Not Pinned |
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HEAD AND NECK |
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Face Directly Up |
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Face Directly Down |
Face to Right |
Face to Left |
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Neck Flexed to Chin |
Neck Extended Back |
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USUAL SLEEPING POSITION |
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On Stomach |
On Back |
Seated Upright |
Left Side |
Right Side |
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46. WAS AIRWAY OBSTRUCTED WHEN DISCOVERED? |
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Airway Not Obstructed |
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Right Nostril Blocked |
Object Covering Mouth |
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Objects Near Face |
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Both Nostrils Blocked |
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Left Nostril Blocked |
Object Covering Nose |
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47. DESCRIBE ANY OBJECTS COVERING NOSE, MOUTH OR FACE: |
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48. IF CHILD WAS FOUND FACE DOWN, IS THERE A VISIBLE CUP, POCKET OR DEPRESSION IN THE BEDDING? |
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NO |
YES |
Depth: |
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Diameter: |
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49. IS THERE A VISIBLE CREASE ON FACE, NECK OR HANDS FROM PILLOWS OR BEDDING? |
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NO |
YES |
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50. MATERIAL FOUND IN NOSE OR MOUTH: |
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None |
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Formula |
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Bloody Froth |
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Blood Tinged Secretion |
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Mucous |
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Vomit |
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Dried Secretion |
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Other |
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Food |
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Froth |
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Urine or Stool |
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51. SECRETION FOUND ON: |
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Blanket |
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Sheet |
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Clothing |
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Pillow |
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Other Item |
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52. WHAT TYPE OF SECRETION |
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None |
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Formula |
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Bloody Froth |
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Blood Tinged Secretion |
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Mucous |
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Vomit |
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Dried Secretion |
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Other Secretion |
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Food |
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Froth |
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Urine or Stool |
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53. FACE IN CONTACT WITH WET MATERIALS |
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DESCRIBE: |
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NO |
YES |
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54. IF FOUND WHILE SLEEPING, WAS CHILD SLEEPING ALONE? |
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NO |
YES |
If no, who was child sleeping with? |
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55. DESCRIBE BED AND/OR OTHER SLEEPING SURFACE. |
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56. LIST ALL MATERIALS AND OBJECTS NEAR CHILD WHEN FOUND, INCLUDING BED, SHEETS, PILLOWS, COVERS, TOYS, HOUSEHOLD OBJECTS, ETC. |
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57. COULD ANY OF THESE MATERIALS AND OBJECTS HAVE INFLUENCED THE DEATH? |
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NO |
Yes |
If yes, describe in narrative. |
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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. |
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NO |
YES |
If yes, explain in narrative. |
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59. IS THERE AN APNEA MONITOR IN THE HOME? |
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WAS CHILD ON MONITOR AT TIME OF DEATH? |
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NO |
YES |
Download information from monitor. |
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NO |
YES |
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Collect monitor as evidence. |
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SOCIAL AND ENVIRONMENTAL CONDITIONS |
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60. WHO DOES CHILD LIVE WITH? |
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61. WHO HAD RESPONSIBILITY FOR CHILD AT TIME OF DEATH? IN NARRATIVE, DESCRIBE |
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ACTIVITIES OF CAREGIVERS DURING DAYS LEADING UP TO THE DEATH. |
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62. HAVE FAMILY MEMBERS OR CARETAKERS BEEN REPORTED FOR PAST ABUSE OR NEGLECT? |
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FOR DOMESTIC VIOLENCE? |
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NO |
YES |
Contact Hotline to obtain information. |
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NO |
YES |
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63. LIST CHILD CARE PROVIDERS - LICENSED |
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UNLICENSED |
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64. DO SIBLINGS EVER WATCH CHILD UNATTENDED? |
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65. ARE THERE ANY CULTURAL PRACTICES THAT MAY HAVE INFLUENCED THE DEATH? |
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NO |
YES |
If yes, age: |
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NO |
YES |
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If yes, explain fully in the narrative. |
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66. DESCRIPTION OF DWELLING: |
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67. CLEANLINESS OF DWELLING |
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BELOW AVERAGE |
ABOVE AVERAGE |
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AVERAGE |
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68. NUMBER OF CHILDREN LIVING AT ADDRESS |
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NUMBER OF ADULTS |
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OVERCROWDED? |
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NO |
YES |
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69. ARE THERE ANY ENVIRONMENTAL HAZARDS? |
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YES |
If yes, check all that apply. |
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Tobacco Smoke |
High Room Temp |
Recent Remodeling |
Tobacco |
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Animals |
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Drugs or Alcohol |
Low Room Temp |
Toxic Gases |
Lead |
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Other |
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Medicines |
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Unusual Dampness |
Toxic Products |
Electrical |
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70. ROOM TEMPERATURE |
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OUTSIDE TEMPERATURE |
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HEATING/COOLING SOURCE |
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PROXIMITY OF CHILD TO HEAT/COOLING SOURCE |
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CHECKLIST FOR DISCRETIONARY COLLECTION OF EVIDENCE |
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Clothing |
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Medicines |
Baby Bottles |
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Toys |
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Bedding |
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Drug Paraphernalia |
Formula/Food |
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Equipment |
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Diapers |
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Folk Remedies |
Honey, if fed within 30 days |
Other |
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TRACE EVIDENCE COLLECTED: LIST |
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LOCATION FOUND |
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DISPOSITION AND PRESENT LOCATION |
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PHOTOS TAKEN? |
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NO |
YES |
If yes, by whom? |
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ALL WITNESSES, RESPONDERS, AND OTHER PERSONS AT SCENE |
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List all persons at scene during time child died. |
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NAME |
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ADDRESS |
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RELATIONSHIP |
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NARRATIVE (USE ADDITIONAL PAGES AS NECESSARY) |
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71. DATE/TIME OF INVESTIGATION |
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72. CASE NUMBER |
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73. INVESTIGATOR’S NAME |
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74. AGENCY/DEPARTMENT |
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MO