Suidi Reporting Form PDF Details

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QuestionAnswer
Form NameSuidi Reporting Form
Form Length8 pages
Fillable?No
Fillable fields0
Avg. time to fill out2 min
Other namescdc suidirf, suidi reporting form, death reporting form, sudden death form

Form Preview Example

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):
:
Location (room):

 

 

 

 

 

 

 

 

 

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

Sudden Unexplained Infant Death Investigation

 

Centers for Disease Control and Prevention

SUIDI

 

 

 

 

 

Division of Reproductive Health

 

 

 

 

Maternal and Infant Health Branch

 

 

 

 

 

Atlanta, Georgia 30333

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:

City:

County:

County:

State:

State:

Zip:

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?

No

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?

No

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

Unknown

Unknown

13

Face position when LAST PLACED?

Face down on surface

Face up

Face right

Face left

 

 

 

 

 

 

 

 

14

Neck position when LAST PLACED?

Hyperextended (head back)

Flexed (chin to chest)

Neutral

Turned

 

 

 

 

 

 

 

 

 

 

 

15

Face position when LKA?

Face down on surface

 

Face up

 

Face right

 

Face left

 

 

 

 

 

 

 

 

 

 

 

16

Neck position when LKA?

Hyperextended (head back)

Flexed (chin to chest)

Neutral

 

Turned

 

 

 

 

 

 

 

 

 

 

 

17

Face position when FOUND?

Face down on surface

 

Face up

 

Face right

 

Face left

 

 

 

 

 

 

 

 

 

 

 

18

Neck position when FOUND?

Hyperextended (head back)

Flexed (chin to chest)

Neutral

 

Turned

 

 

 

 

 

 

 

 

 

 

19

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

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

20

Was the infant tightly wrapped or swaddled?

No

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

 

 

 

 

 

 

 

 

23

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

 

 

 

 

 

 

 

26

Was anyone sleeping with the infant?

 

 

No

 

Yes

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Other -

 

 

 

 

Location in relation

 

Name of individual sleeping with infant Age

Height Weight

to infant

Imparement (intoxication, tired)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

27

Was there evidence of wedging?

 

No

 

 

Yes - Describe:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

28

When the infant was found, was s/he:

 

 

Breathing

 

 

Not Breathing

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

 

 

 

No

 

 

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

31

32

33

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?

 

No

 

 

 

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:

No

Yes

INFANT MEDICAL HISTORY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1

 

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

 

 

 

 

 

 

 

 

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:

No

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:

 

 

 

 

 

 

 

 

 

 

9

 

What was the infant’s length at birth?

 

inches or

 

centimeters

 

 

 

 

 

 

 

 

 

 

 

 

 

10

What was the infant’s weight at birth?

 

pounds

 

ounces or

 

 

 

 

 

 

 

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

No

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

Yes

No

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

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

5

 

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

 

No

 

Yes

 

 

 

 

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

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

6

 

Was the infant last placed to sleep with a bottle?

 

 

Yes

 

No - if no, skip to question 9 below

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

7

 

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

 

 

No

 

 

Yes

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

8

 

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

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

9

 

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)

No

Yes

If yes, - describe:

PREGNANCY HISTORY

1

Information about the infant’s birth mother:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

First name:

 

 

 

 

 

 

 

Last name:

 

Middle name:

 

 

 

 

 

 

Maiden name:

 

 

 

 

 

 

 

 

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)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

No

Yes

Daily

 

Unknown

No

Yes

Daily

 

 

a) Over the counter medications

 

 

 

 

 

d) Cigarettes

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

b) Prescription medications

 

 

 

 

 

e) Alcohol

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

c) Herbal remedies

 

 

 

 

 

f) Other

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

7

 

Currently, does any caregiver use any of the following?

 

 

 

 

 

 

 

 

 

Unknown

No

Yes

Daily

 

Unknown

No

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

 

 

Ceiling fan

 

Electric space heater

 

Kerosene space heater

 

 

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

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2

 

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

 

 

No

 

 

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

1

2

Investigator information Name:

 

 

 

 

 

 

 

 

Agency:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date

 

 

 

Military time

 

 

 

 

 

 

 

 

 

 

Investigated:

 

 

 

 

 

 

 

 

:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Pronounced dead:

 

 

 

 

 

 

 

 

:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Infant’s information:

 

Last:

 

 

 

 

 

 

First:

 

 

 

 

 

 

M:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Sex:

 

Male

 

 

Female

Date of Birth:

 

 

 

 

 

 

 

 

Age:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Race:

 

White

 

 

Black/African Am.

 

 

Asian/Paciic Islander

 

 

 

 

 

 

 

Am. Indian/Alaskan Native

 

Hispanic/Latino

 

 

 

Other:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Phone:

Case #:

1

Sleeping Environment

Infant History

Family Info

Exam

InsightInvestigator

2

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:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Page 8