Suidi Reporting Form - Sudden Unexplained Infant Death Investigation Page 3
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8WITNESS INTERVIEW (cont.)
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What had led you to check on the infant?
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Describe infant’s appearance when found.
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
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What did the infant feel like when found? (Check all that apply.)
Sweaty
Warm to touch
Cool to touch
Limp, flexible
Rigid, stiff
Unknown
Other
Specify: .................................
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Yes
Who and when?
No
Did anyone else other than EMS try to resuscitate the infant?
:
Who ______________________________________________________________
/
/
Month
Day
Year
Military Time
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Please describe what was done as part of resuscitation:
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No
Yes
Explain
Has the parent/caregiver ever had a child die suddenly and unexpectedly?
INFANT MEDICAL HISTORY
1
Doctor
Other healthcare provider
Medical record
Source of medical information:
Mother/primary caregiver
Family
Other:
2
In the 72 hours prior to death, did the infant have:
Unknown No Yes
Unknown No
Yes
a) Fever
h) Diarrhea
b) Excessive sweating
i) Stool changes
c) Lethargy or sleeping more than usual
j) Difficulty breathing
d) Fussiness or excessive crying
k) Apnea (stopped breathing)
e) Decrease in appetite
l) Cyanosis (turned blue/gray)
f) Vomiting
m) Seizures or convulsions
g) Choking
n) Other, specify:
3
In 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?
(Please include any home remedies, herbal medications, prescription medicines, over-the-counter medications.)
No
Yes
List below
Name of vaccination or medication
Dose last given
Date given
Approx. time
Reasons given/
comments:
Month
Day
Year
Military Time
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