Suidi Reporting Form - Sudden Unexplained Infant Death Investigation Page 2
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8WITNESS INTERVIEW (cont.)
10
In what position was the infant LAST PLACED?
On stomach
Sitting
On back
On side
Unknown
Was this the infant’s usual position?
Yes
No
What was the infant’s usual position?
11
In what position was the infant LKA?
On stomach
Sitting
On back
On side
Unknown
Was this the infant’s usual position?
Yes
No
What was the infant’s usual position?
12
In what position was the infant Found?
On stomach
Sitting
On back
On side
Unknown
Was this the infant’s usual position?
Yes
No
What was the infant’s usual position?
13
FACE
LAST PLACED?
Face up
Face right
Face down on surface
Face left
position when
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NECK
LAST PLACED?
Flexed (chin to chest)
Neutral
position when
Hyperextended (head back)
Turned
15
FACE
LKA?
Face down on surface
Face up
Face right
Face left
position when
16
NECK
LKA?
Hyperextended (head back)
Flexed (chin to chest)
Neutral
Turned
position when
17
FACE
FOUND?
Face up
Face right
position when
Face down on surface
Face left
18
NECK
FOUND?
Flexed (chin to chest)
Neutral
position when
Hyperextended (head back)
Turned
19
What was the infant wearing?
(ex. t-shirt, disposable diaper)
20
Was the infant tightly wrapped or swaddled?
No
Yes
Describe:
21
Please 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
...........................................
Rubber or plastic sheet
................
Rubber or plastic sheet ....................
Other, specify:
..............................
Other, specify:
...............................
22
Which of the following devices were operating in the infant’s room?
None
Apnea monitor
Humidifi er
Vaporizer
Air Purifier
Other
23
What was the temperature of the infant’s room?
Hot
Cold
Normal
Other
24
What was the infant’s temperature?
25
Which of the following items were near the infant’s face, nose, or mouth?
Bumper pads
Infant pillows
Positional supports
Stuffed animals
Toys
Other
26
Which of the following items were within the infant’s reach?
Blankets
Toys
Pillows
Pacifi er
Nothing
Other
27
No
Yes
Name these people.
Was anyone sleeping with the infant?
Name
Age
Height
Weight
Location in Relation to Infant
Impaired (intoxicated, tired)
28
No
Yes
Discribe:
Was there evidence of wedging?
29
When the infant was found, was s/he:
Breathing
Not breathing
If not breathing, did you witness the infant stop breathing?
No
Yes
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