Suidi Reporting Form - Sudden Unexplained Infant Death Investigation Page 6
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8PREGNANCY HISTORY (cont.)
4
During her pregnancy with the infant, did the biological mother have any complications?
(ex. high blood pressure, bleeding, gestational diabetes)
No
Yes
Specify
5
Was the biological mother injured during her pregnancy with the infant?
(ex. auto accident, falls)
No
Yes
Specify
6
During her pregnancy, did she use any of the following?
Unknown
No Yes Daily consumption
Unknown No Yes Daily consumption
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 consumption
Unknown No Yes Daily consumption
a) Over the counter medications
d) Cigarettes
b) Prescription medications
e) Alcohol
c) Herbal remedies
f) Other
INCIDENT SCENE INVESTIGATION
1
____________________________________________________________
Where did the incident or death occur?
2
Was this the primary residence?
Yes
No
3
Is the site of the incident or death scene a daycare or other childcare setting?
No
Skip to question 8 below
Yes
4
How many children were under the care of the provider at the time of the incident or death?
(under 18 years or older)
5
How many adults were supervising the child(ren)?
(18 years or older)
6
What is the license number and licensing agency for the daycare?
License number:
Agency:
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______________________________________________________
How long has the daycare been open for business?
8
How 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)
9
Which of the following heating or cooling sources were being used? (Check all that apply.)
Central air
Gas furnace or boiler
Wood burning fireplace
Open window(s)
A/C window unit
Electric furnace or boiler
Coal burning furnace
Wood burning stove
Ceiling fan
Electric space heater
Kerosene space heater
________________________
Floor/table fan
Electric baseboard heat
Other
Specify
Window fan
Electric (radiant) ceiling heat
Unknown
10
Indicate the temperature of the room where the infant was found unresponsive:
Thermostat setting
Thermostat reading
Actual room temp.
Outside temp.
11
What was the source of drinking water at the site of the incident or death scene?
(Check all that apply.
)
Public/municipal water source
Bottled water
Other
Specify _____________________
Well
Unknown
12
The site of the incident or death scene has: (check all that apply)
Insects
Mold growth
Odors or fumes
Describe:
Smoky smell (like cigarettes)
Pets
Presence of alcohol containers
Dampness
Peeling paint
Presence of drug paraphenalia
Visible standing water
Rodents or vermin
Other
Specify _____________________
13
Describe the general appearance of incident scene: (ex. cleanliness, hazards, overcrowding, etc.)
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