Suidi Reporting Form - Sudden Unexplained Infant Death Investigation Page 8
ADVERTISEMENT
1
2
3
4
5
6
7
8SUMMARY FOR PATHOLOGIST
Investigator Information: Name _______________________________ Agency ________________
Phone ________________
_____/ _____ / _______
_____ : _____
Investigated:
Pronounced Dead: _______/ ____ / ______
______ : ______
Month
Day
Year
Military Time
Month
Day
Year
Military Time
Infant’s Information:
Last ___________________________
First _____________________ M. ______ Case # ____________
Sex:
Male
Female
Date of Birth
______ / _____ / ________
Age ____________
Month
Day
Year
Months
Race:
White
Black/African Am.
Asian/Pacifi c Islander
Am. Indian/Alaskan Native
Hispanic/Latino
Other
1
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 sleeping surface with adults, children, or pets
Change in sleeping 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 sleeping conditions (ex. couch/sofa, waterbed, stuffed toys, pillows, soft bedding)
Diet (e.g., solids introduction etc.)
Recent hospitalization
Previous medical diagnosis
History of acute life-threatening events (ex. apnea, seizures, diffi culty 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 should be explained and detailed.
Brief description of circumstances: _____________________________________________________________________________
2
Pathologist Information:
Name ___________________________________________
Agency _______________________________________________
Phone ( _______ ) _________ - ______________________ Fax ( _______ ) _________ - ______________________
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business