Suidi Reporting Form - Sudden Unexplained Infant Death Investigation

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Reporting Form
INVESTIGATION DATA
Infant’s Information:
Last: ______________________
First: _______________ M. _____
Case#
Sex:
Male
Female
Date of Birth
/
/
Age
SS#
Month
Day
Year
Race:
White
Black/African Am.
Asian/Pacific Islander
Am. Indian/Alaskan Native
Hispanic/Latino
Other
Infant’s Primary Residence Address:
Address
City
Zip
Incident Address:
Address
City
Zip
Contact Information for Witness:
Relationship to the deceased:
Birth Mother
Birth Father
Grandmother
Grandfather
Adoptive or Foster Parent
Physician
Health Records
Other:
Last
First
M.
SS#
Home Address
City
State
Zip
Place of Work
City
State
Zip
Phone (H)
Phone (W)
Date of Birth
WITNESS INTERVIEW
1
Are you the usual caregiver?
Yes
No
2
Tell me what happened:
3
Did you notice anything unusual or different about the infant in the last 24 hrs?
No
Yes
Describe: ___________
4
Did the infant experience any falls or injury within the last 72 hrs?
No
Yes
Describe: ___________
:
5
/
/
When was the infant LAST PLACED?
..................
Month
Day
Year
Military T
ime
Location (room)
:
6
/
/
When was the infant
LAST KNOWN ALIVE (LKA)
?
Month
Day
Year
Military T
ime
Location (room)
:
7
/
/
When was the infant FOUND?
............ .................
Month
Day
Year
Military T
ime
Location (room)
8
Explain how you knew the infant was still alive.
9
Where was the infant - (P)laced, (L)ast known alive, (F)ound (circle P, L, or F in front of appropriate response)?
P L F Bassinet
P L F Bedside co-sleeper
P L F Car seat
P L F Chair
P L F Cradle
P L F Crib
P L F Floor
P L F In a person’s arms
P L F Mattress/box spring
P L F Mattress on floor
P L F Playpen
P L F Portable crib
P L F Sofa/couch
P L F Stroller/carriage
P L F Swing
P L F Waterbed
________________________________________________________________________________________________
P L F Other

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