Suidi Reporting Form – Fill Out and Use This PDF

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Other - describe:

Portable crib Waterbed

Mattress/box spring Sofa/couch

Mattress on loor Stroller/carriage

Chair

In a person’s arms

Bassinet Cradle

Bedside co-sleeper Crib

8 Explain how you knew the infant was still alive.

9 Where was the infant - (P)laced, (L)ast known alive, (F)ound (write P, L, or F in front of appropriate response)? Car seat

Floor

Playpen

Swing

Location (room):

Date:Military Time:

Location (room):


U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES			Sudden Unexplained Infant Death Investigation
Centers for Disease Control and Prevention			SUIDI
Centers for Disease Control and Prevention
Division of Reproductive Health
Maternal and Infant Health Branch
	Atlanta, Georgia 30333		Reporting Form
			Reporting Form


			INVESTIGATION DATA
Infant’s Last Name		Infant’s First Name	Middle Name	Case Number

Sex:

Race:

White

Date of Birth:

Black/African Am.

Asian/Paciic Isl.

Age:		SS#:

Am. Indian/Alaskan Native

Hispanic/Latino

Other

Infant’s Primary Residence: Address:

Incident

Address:

Contact Information for Witness:

City:

County:

State:

Zip:

Relationship to deceased:

Birth Mother

Birth Father

Grandmother

Grandfather

Adoptive or Foster Parent

Physician

Health Records

Other Describe:

Last:

First:

M.:

SS#:

Address:

City:

State:

Zip:

Work Address:

City:

State:

Zip:

Home Phone:

Work Phone:

Date of Birth:

WITNESS INTERVIEW

1Are you the usual caregiver?

Yes

2Tell me what happened:

3Did you notice anything unusual or different about the infant in the last 24 hrs?

No		Yes	Specify:

4Did the infant experience any falls or injury within the last 72 hrs?

Yes Specify:

5When was the infant LAST PLACED?

Date:		Military Time:

6When was the infant LAST KNOWN ALIVE(LKA)?

Date:		Military Time:

7When was the infant FOUND?

WITNESS INTERVIEW (cont.)

10In what position was the infant LAST PLACED? Was this the infant’s usual position?

11In what position was the infant LKA? Was this the infant’s usual position?

12In what position was the infant FOUND? Was this the infant’s usual position?

Sitting

Yes

Sitting

Yes

Sitting

Yes

On back	On side	On stomach
No	What was the usual position?
On back	On side	On stomach
No	What was the usual position?
On back	On side	On stomach
No	What was the usual position?

Unknown

Face position when LAST PLACED?

Face down on surface

Face up

Face right

Face left

Neck position when LAST PLACED?

Hyperextended (head back)

Flexed (chin to chest)

Neutral

Turned

Face position when LKA?

Face down on surface

Face up

Face right

Face left

Neck position when LKA?

Hyperextended (head back)

Flexed (chin to chest)

Neutral

Turned

Face position when FOUND?

Face down on surface

Face up

Face right

Face left

Neck position when FOUND?

Hyperextended (head back)

Flexed (chin to chest)

Neutral

Turned

What was the infant wearing? (ex. t-shirt, disposable diaper)

Was the infant tightly wrapped or swaddled?

Yes - describe:

21Please indicate the types and numbers of layers of bedding both over and under infant (not including wrapping blanket):

Bedding UNDER Infant	None	Number Bedding OVER Infant		None	Number
Receiving blankets			Receiving blankets

Infant/child blankets			Infant/child blankets

Infant/child comforters (thick)			Infant/child comforters (thick)

Adult comforters/duvets			Adult comforters/duvets

Adult blankets			Adult blankets

Sheets			Sheets

Sheepskin			Pillows

Pillows			Other, specify:

Rubber or plastic sheet

Other, specify:

22Which of the following devices were operating in the infant’s room?

None

Apnea monitor

Humidiier

Vaporizer

Air puriier

In was the temperature in the infant’s room?

Hot

Cold

24Which of the following items were near the infant’s face, nose, or mouth?

Other -
Normal	Other -

Bumper pads

Infant pillows

Positional supports

Stuffed animals

Toys

Other -

25Which of the following items were within the infant’s reach?

Blankets

Toys

Pillows

Paciier

Nothing

Was anyone sleeping with the infant?

Yes

Other -

		Location in relation
Name of individual sleeping with infant Age	Height Weight	to infant	Imparement (intoxication, tired)

Was there evidence of wedging?

Yes - Describe:

When the infant was found, was s/he:

Breathing

Not Breathing

If not breathing, did you witness the infant stop breathing?

Yes

Page 2

WITNESS INTERVIEW (cont.)

29What had led you to check on the infant?

30Describe the infant’s appearance when found.

Appearance

Unknown No Yes

Describe and specify location

a)Discoloration around face/nose/mouth

b)Secretions (foam, froth)

c)Skin discoloration (livor mortis)

d)Pressure marks (pale areas, blanching)

e)Rash or petechiae (small, red blood spots on skin, membranes, or eyes)

f)Marks on body (scratches or bruises)

g)Other

What did the infant feel like when found? (Check all that apply.)

Sweaty

Warm to touch

Cool to touch

Limp, lexible

Rigid, stif

Unknown

Other - specify:

Did anyone else other than EMS try to resuscitate the infant?

Yes

Who?

Date:

Military time:

Please describe what was done as part of resuscitation:

34Has the parent/caregiver ever had a child die suddenly and unexpectedly? Explain:

Yes

INFANT MEDICAL HISTORY

Source of medical information:

Doctor

Other healthcare provider

Medical record

Family

Mother/primary caregiver

Other:

2In the 72 hours prior to death, did the infant have:

Condition		Unknown No Yes Condition			Unknown No Yes

a) Fever			k)	Apnea (stopped breathing)
h) Diarrhea			e)	Decrease in appetite
b) Excessive sweating			l)	Cyanosis (turned blue/gray)

i)	Stool changes		f)	Vomiting

c)	Lethargy or sleeping more than usual		m) Seizures or convulsions

j)	Dificulty breathing		g) Choking

d)	Fussiness or excessive crying		n) Other, specify:

3In the 72 hours prior to death, was the infant injured or did s/he have any other condition(s) not mentioned?

		No	Yes - describe:


4	In the 72 hours prior to the infants death, was the infant given any vaccinations or medications?			No	Yes

(Please include any home remedies, herbal medications, prescription medicines, over-the-counter medications.)

		Date given		Approx. time
				Approx. time
Name of vaccination or medication	Dose last given Month Day		Year	(Military Time)	comments:

1.

2.

3.

4.

Page 3

INFANT MEDICAL HISTORY (cont.)

5At any time in the infant’s life, did s/he have a history of?

Medical history

Unknown No Yes

Describe

a)Allergies (food, medication, or other)

b)Abnormal growth or weight gain/loss

c)Apnea (stopped breathing)

d)Cyanosis (turned blue/gray)

e)Seizures or convulsions

f)Cardiac (heart) abnormalities

6Did the infant have any birth defects(s)? Describe:

Yes

7Describe the two most recent times that the infant was seen by a physician or health care provider:

(Include emergency department visits, clinic visits, hospital admissions, observational stays, and telephone calls)

First most recent visit

Second most recent visit

a)Date

b)Reason for visit

c)Action taken

d)Physician’s name

e)Hospital/clinic

f)Address

g)City

h)State, ZIP

i)Phone number

8Birth hospital name: Street address:

City:

Discharge date:

State:		Zip:

11Compared to the delivery date, was the infant born on time, early, or late?

grams

On time

Early - how many weeks?

Late - how many weeks?

12Was the infant a singleton, twin, triplet, or higher gestation?

Singleton		Twin		Triplet		Quadrupelet or higher gestation

13Were there any complications during delivery or at birth? (emergency c-section, child needed oxygen) Describe:

Yes

14Are there any alerts to the pathologist? (previous infant deaths in family, newborn screen results) Specify:

Yes

Page 4

INFANT DIETARY HISTORY

1On what day and at what approximate time was the infant last fed?

Date:

Military Time:

2 What is the name of the person who last fed the infant? 3 What is his/her relationship to the infant?

4What foods and liquids was the infant fed in the last 24 hours (include last fed)?

Food	Unknown No Yes Quantity (ounces) Specify: (type and brand)

a)Breast milk (one/both sides, length of time)

b)Formula (brand, water source - ex. Similac, tap water)

c)Cow’s milk

d)Water (brand, bottled, tap, well)

e)Other liquids (teas, juices)

f)Solids

g)Other

Was a new food introduced in the 24 hours prior to his/her death?

Yes

If yes, describe (ex. content, amount, change in formula, introduction of solids)

Was the infant last placed to sleep with a bottle?

Yes

No - if no, skip to question 9 below

Was the bottle propped? (i.e., object used to hold bottle while infant feeds)

Yes

If yes, what object was used to prop the bottle?

What was the quantity of liquid (in ounces) in the bottle?

Did the death occur during?

Breast-feeding

Bottle-feeding

Eating solid foods

Not during feeding

10Are there any factors, circumstances, or environmental concerns that may have impacted the infant that have not yet been identiied? (ex. exposed to cigarette smoke or fumes at someone else’s home, infant unusually heavy, placed with positional supports or wedges)

Yes

If yes, - describe:

PREGNANCY HISTORY

1	Information about the infant’s birth mother:

	First name:				Last name:
	Middle name:			Maiden name:
	Middle name:			Maiden name:
	Birth date:				SS#:
	Birth date:				SS#:


	Street address:		City:


	How long has the birth mother been at this address?	Years:


	Previous Address:

State:

Months:

Zip:

2At how many weeks or months did the birth mother begin prenatal care?

Weeks:		Months:

No parental care

Unknown

3Where did the birth mother receive prenatal care? (Please specify physician or other health care provider name and address.)

Physician/provider:		Hospital/clinic:		Phone:

Street address:

City:

State:

Zip:

Page 5

Other - specify:

10 Indicate the temperature of the room where the infant was found unresponsive:

PREGNANCY HISTORY (cont.)


4	At how many weeks or months did the birth mother begin prenatal care?	No	Yes
	(ex. high blood pressure, bleeding, gestational diabetes)
	(ex. high blood pressure, bleeding, gestational diabetes)

	Specify:

5	Was the birth mother injured during her pregnancy with the infant? (ex. auto accident, falls)			No	Yes

Specify:

6During her pregnancy, did she use any of the following?

Unknown

Yes

Daily

Unknown

Yes

Daily

a) Over the counter medications

d) Cigarettes

b) Prescription medications

e) Alcohol

c) Herbal remedies

f) Other

Currently, does any caregiver use any of the following?

Unknown

Yes

Daily

Unknown

Yes

Daily

a) Over the counter medications

d) Cigarettes

b) Prescription medications

e) Alcohol

c) Herbal remedies

f) Other

INCIDENT SCENE INVESTIGATION

1Where did the incident or death occur?


2	Was this the primary residence?	No	Yes


3	Is the site of the incident or death scene a daycare or other childcare setting?			Yes	No - If no, skip to question 8

4How many children (under age 18) were under the care of the provider at the time of the incident or death?

5 How many adults (age 18 and over) were supervising the child(ren)?

6What is the license number and licensing agency for the daycare?

License number:

Agency:

7How long has the daycare been open for business?

8How many people live at the site of the incident or death scene?

Number of adults (18 years or older):		Number of children (under 18 years old):

9Which of the following heating or cooling sources were being used? (Check all that apply)

Central air	Gas furnace or boiler	Wood burning ireplace
A/C window unit	Electric furnace or boiler	Coal burning furnace
A/C window unit	Electric furnace or boiler	Coal burning furnace
Ceiling fan	Electric space heater	Kerosene space heater
Ceiling fan	Electric space heater	Kerosene space heater
Electric baseboard heat	Electric (radiant) ceiling heat	Window fan
Electric baseboard heat	Electric (radiant) ceiling heat	Window fan

Open window(s) Wood burning stove Floor/table fan Unknown

Thermostat setting

Thermostat reading

Actual room temp.

Outside temp.

11What was the source of drinking water at the site of the incident or death scene? (Check all that apply.)

Public/municipal water		Bottled water		Well

12The site of the incident or death scene has: (check all that apply)

Unknown

Other - Specify:

Insects

Pets Peeling paint Rodents or vermin

Other - specify:

Mold growth

Dampness

Visible standing water

Odors or fumes - Describe:

Smoky smell (like cigarettes) Presence of alcohol containers Presence of drug paraphenalia

13Describe the general appearance of incident scene: (ex. cleanliness, hazards, overcrowding, etc.) Specify:

Page 6

INVESTIGATION SUMMARY

1Are there any factors, circumstances, or environmental concerns about the incident scene investigation that may have impacted the infant that have not yet been identiied?

2Arrival times

Law enforcement at scene:

DSI at scene:

Infant at hospital:

Military time

Investigator’s Notes

1Indicate the task(s) performed

Additional scene(s)? (forms attached)

Doll reenactment/scene re-creation

Photos or video taken and noted

Materials collected/evidence logged

Referral for counseling

EMS run sheet/report

Notify next of kin or verify notiication

911 tape

If more than one person was interviewed, does the information differ?

Yes

If yes, detail any differences, inconsistencies of relevant information: (ex. placed on sofa, last known alive on chair.)

INVESTIGATION DIAGRAMS

1Scene Diagram:

2Body Diagram:

Page 7

SUMMARY FOR PATHOLOGIST

Case Information

Investigator information Name:

Agency:

Date

Military time

Investigated:

Pronounced dead:

Infant’s information:

Last:

First:

Sex:

Male

Female

Date of Birth:

Age:

Race:

White

Black/African Am.

Asian/Paciic Islander

Am. Indian/Alaskan Native

Hispanic/Latino

Other:

Phone:

Case #:

Sleeping Environment

Infant History

Family Info

Exam

InsightInvestigator

Pathologist

Indicate whether preliminary investigation suggests any of the following:

Yes No

Asphyxia (ex. overlying, wedging, choking, nose/mouth obstruction, re-breathing, neck compression, immersion in water) Sharing of sleep surface with adults, children, or pets

Change in sleep condition (ex. unaccustomed stomach sleep position, location, or sleep surface)

Hyperthermia/Hypothermia (ex. excessive wrapping, blankets, clothing, or hot or cold environments)

Environmental hazards (ex. carbon monoxide, noxious gases, chemicals, drugs, devices)

Unsafe sleep condition (ex. couch/sofa, waterbed, stuffed toys, pillows, soft bedding)

Diet (e.g., solids introduced, etc.)

Recent hospitalization

Previous medical diagnosis

History of acute life-threatening events (ex. apnea, seizures, dificulty breathing)

History of medical care without diagnosis

Recent fall or other injury

History of religious, cultural, or ethnic remedies

Cause of death due to natural causes other than SIDS (ex. birth defects, complications of preterm birth) Prior sibling deaths

Previous encounters with police or social service agencies

Request for tissue or organ donation

Objection to autopsy

Pre-terminal resuscitative treatment

Death due to trauma (injury), poisoning, or intoxication

Suspicious circumstances

Other alerts for pathologist’s attention

Any “Yes” answers above should be explained in detail (description of circumstances):

Pathologist information	Name:

Agency:		Phone:	Fax:
Agency:		Phone:	Fax:

Page 8

Question	Answer
Form Name	Suidi Reporting Form
Form Length	8 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	2 min
Other names	cdc suidirf, suidi reporting form, death reporting form, sudden death form

What was the infant’s length at birth?

centimeters

What was the infant’s weight at birth?