NCFRP Cases Reporting System SDY Module 1

I.

OTHER CIRCUMSTANCES OF INCIDENT - ANSWER RELEVANT SECTIONS

I1. SUDDEN AND UNEXPECTED DEATH IN THE YOUNG (SDY)

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Section I1: OMB No. 0920-1092, Exp. Date: 4/30/2022
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a. Was this death:

A homicide?
A suicide?
An overdose?

If any of these apply, go to Section I2,

A result of an external cause that was the obvious and only reason for the fatal injury?

THIS IS NOT AN SDY CASE.

Expected within 6 months due to terminal illness?
None of the above, go to I1b THIS IS AN SDY CASE
U/K, go to I1b
b. Did the child have a history of any of the following acute conditions or symptoms within 72 hours prior to death?

c. At any time more than 72 hours preceding death did the
child have a personal history of any of the following

U/K for all

chronic conditions or symptoms?
Present w/in 72 hours of death

Symptom
Cardiac

Yes

No

Present w/in 72 hours of death Symptom

Other Acute Symptom

U/K

Yes

No

Cardiac

U/K

U/K for all

Present more than 72 hours of death
Yes

Chest pain

Fever

Chest pain

Dizziness/lightheadedness

Heat exhaustion/heat stroke

Dizziness/lightheadedness

Fainting

Muscle aches/cramping

Fainting

Palpitations

Slurred speech

Neurologic

Vomiting

Concussion

Other, specify:

No

U/K

Palpitations
Neurologic
Concussion

Confusion

Confusion

Convulsions/seizure

Convulsions/seizure

Headache

Headache

Head injury

Head injury
Respiratory

Psychiatric symptoms
Paralysis (acute)

Difficulty breathing

Respiratory

Other

Asthma

Slurred speech

Pneumonia

Other, specify:

Difficulty breathing
d. Did the child have any prior serious injuries (e.g. near drowning, car accident, brain injury)?
Yes

No

U/K

If yes, describe:

e. Had the child ever been diagnosed by a medical professional for the following?
Diagnosed
Condition
Condition
Blood disease

Yes

No

U/K

U/K for all

Neurologic

Yes

Sickle cell disease

Anoxic brain Injury

Sickle cell trait

Traumatic brain injury/

Thrombophilia (clotting disorder)
Cardiac
Abnormal electrocardiogram
(EKG or ECG)
Aneurysm or aortic dilatation

Diagnosed

head injury/concussion
Brain tumor

No

Condition
U/K

Other

Yes

Connective tissue disease
Diabetes
Endocrine disorder, other:
thyroid, adrenal, pituitary

Brain aneurysm

Hearing problems or deafness

Brain hemorrhage

Kidney disease

Developmental brain disorder

Mental illness/psychiatric disease

Arrhythmia/arrhythmia syndrome

Epilepsy/seizure disorder

Metabolic disease

Cardiomyopathy

Febrile seizure

Muscle disorder or muscular

Commotio cordis

Mesial temporal sclerosis

Congenital heart disease

Neurodegenerative disease

Coronary artery abnormality

Stroke/mini stroke/

Coronary artery disease
(atherosclerosis)
Endocarditis
Heart failure

TIA-Transient Ischemic Attack
Central nervous system infection
(meningitis or encephalitis)
Respiratory
Apnea

High cholesterol

Asthma

Hypertension

Pulmonary embolism

Myocarditis (heart infection)

Pulmonary hemorrhage

Pulmonary hypertension

Respiratory arrest

Sudden cardiac arrest

dystrophy
Oncologic disease treated by
chemotherapy or radiation
Prematurity
Congenital disorder/
genetic syndrome
Other, specify:

Heart murmur

Page 16 of 25

Diagnosed
No

U/K

If a more specific diagnosis is known, provide any additional information:
If any cardiac conditions above are selected, what cardiac treatments did the child have? Check all that apply:

None

Cardiac ablation

Heart surgery

Heart transplant

Cardiac device placement

Interventional cardiac

Other, specify:

(implanted cardioverter defibrillator (ICD)

catheterization

U/K

or pacemaker or Ventricular Assist Device (VAD))
f. Did the child have any blood relatives (brothers, sisters, parents, aunts, uncles, cousins, grandparents or other more distant relatives)
with the following diseases, conditions or symptoms?
Y

g. Has any blood relative (siblings,

U/K for all

parents, aunts, uncles, cousins,
grandparents) had genetic testing?

Deaths

N U/

Sudden unexpected death before age 50

Yes

No

U/K

If yes, describe the type of event, which relative, and relative’s age at death (for example, brother at age 30 who died
in an unexplained motor vehicle accident (driver of car)):
Heart Disease

Y N U/K

Symptoms

If yes, describe the test/gene tested,

Heart condition/heart attack or stroke before age 50

Febrile seizures

reason for testing, family member

Aortic aneurysm or aortic rupture

Unexplained fainting

tested, and results:

Arrhythmia (fast or irregular heart rhythm)

Other Diagnoses

Cardiomyopathy

Congenital deafness

Congenital heart disease

Connective tissue disease

Neurologic Disease

Mitochondrial disease

Epilepsy or convulsions/seizure

Muscle disorder or muscular dystrophy

Other neurologic disease

Thrombophilia (clotting disorder)

Was a gene mutation found?
Yes

No

U/K

Other diseases that are genetic or
run in families, specify:
h. In the 72 hours prior to death was the child taking any prescribed medication(s)?
Yes

No

k. Was the child taking any of the following substance(s) within 24 hours of death?
Check all that apply:

U/K

If yes, describe:
i. Within 2 weeks prior to death had the child:

N/A Yes No

U/K

Over-the-counter medicine

Supplements

Recent/short term prescriptions

Tobacco

Energy drinks

Alcohol

Taken extra doses of prescribed medications

Caffeine

Illegal drugs

Missed doses of prescribed medications

Performance enhancers

Legalized marijuana

Changed prescribed medications, describe:

Diet assisting medications

Other, specify:
U/K

j. Was the child compliant with their prescribed medications?
N/A

Yes

No

If yes to any items above, describe:

U/K

If not compliant, describe why and how often:
l. Did the child experience any of the following stimuli at time of incident or within 24 hours of the incident?
At incident
Stimuli

Yes

No

Within 24 hrs of incident
U/K

Yes

No

U/K for all at time of incident
U/K for all within 24 hours of incident

U/K

Physical activity

If yes to physical activity, describe type of activity:

Sleep deprivation

At incident

Within 24 hours of incident

Driving
Visual stimuli
Video game stimuli
Emotional stimuli
Auditory stimuli/startle
Physical trauma

Other specify:

Other, specify:

At incident

m. Was the child an athlete?

N/A

Yes

If yes, type of sport:

No

Within 24 hours of incident

U/K
Competitive

Recreational

U/K

If competitive, did the child participate in the 6 months prior to death?
n. Did the child ever have any of the following uncharacteristic symptoms during or

Yes

No

U/K

o. For child age 12 or older, did the child receive a pre-participation exam for a sport?

within 24 hours after physical activity? Check all that apply:

N/A

Yes

No

U/K

Chest pain

Headache

If yes:

Confusion

Palpitations

Was it done within a year prior to death?

Convulsions/seizure

Shortness of breath/difficulty breathing

Did the exam lead to restrictions for sports or otherwise?

Dizziness/lightheadedness

Other, specify:

Fainting

U/K

If yes, specify restrictions:

If yes to any item, describe type of physical activity and extent of symptoms:

Page 17 of 25

Yes

No
Yes

U/K
No

U/K

Questions p through v: Answer if "Epilepsy/Seizure Disorder" is answered Yes in question e above (Diagnosed for a medical condition)
p. How old was the child when diagnosed with epilepsy/seizure

r. What type(s) of seizures did the child have? Check all

disorder?

t. How many seizures did the child have in
the year preceding death?

that apply:

Age 0 (infant) through 20 years:
U/K

Non-convulsive

0/never

2

More than 3

Convulsive (grand mal seizure or

1

3

U/K

generalized tonic-clonic seizure)

q. What were the underlying cause(s) of the child’s seizures?
Check all that apply:

u. Did treatment for seizures include
anti-epileptic drugs?

Occur when exposure to strobe lights,

Brain injury/trauma, specify:

Genetic/chromosomal

Brain tumor

Mesial temporal sclerosis

Cerebrovascular

Idiopathic or cryptogenic

Central nervous system

Other acute illness or injury

infection

video game, or flickering light (reflex seizure)

Yes

U/K

1

4

More than 6

Last less than 30 minutes

2

5

U/K

3

6

seizure at time of death). Check all that apply:

Degenerative process

Other, specify:

Last more than 30 minutes (status epilepticus)

Developmental brain disorder

U/K

Occur in the presence of fever (febrile seizure)

Inborn error of metabolism

U/K

epileptic drugs did the child take?

s. Describe the child's epilepsy/seizures (not including the

other than epilepsy

No

If yes, how many different types of anti-

v. Was night surveillance used?

Occur in the absence of fever

Yes

No

U/K

Occur when exposed to strobe lights, video
game, or flickering light (reflex seizure)

I2. ANSWER THIS ONLY IF CHILD IS UNDER AGE FIVE:
OOWAS DEATH RELATED TO SLEEPING OR THE SLEEP ENVIRONMENT?

Yes, go to I2a

No, go to I2s

U/K, go to I2a

a. Incident sleep place:
Crib

Adult bed

Car seat

If crib, type:

Waterbed

Rock 'n Play

Twin

Bed position

Not portable

Futon

Stroller

Full

Couch position

Portable, e.g. Pack 'n Play

Playpen/other play

Swing

Queen

Unknown crib type

structure, not a portable crib

Bouncy chair

King

If car seat, was car seat

Other, specify:

Other, specify:

secured in seat of car?

Bassinet

Couch

Bed side sleeper

Chair

Baby box

Floor

b. Child put to sleep:

If adult bed, what type?

If futon,

U/K

U/K

Yes

No

U/K

U/K

c. Child found:

e. Usual sleep position:

On back

On back

On back

On stomach

On stomach

On stomach

On side

On side

On side

U/K

U/K

U/K

f. Was there any type of crib, Pack 'n Play, bassinet,
bed side sleeper or baby box in home for child?
Yes

No

U/K

d. Usual sleep place:
Crib

Baby box

Floor

If crib, type:

Adult bed

Car seat

If adult bed, what type?
Twin

King

Not portable

Waterbed

Rock 'n Play

Full

Other, specify:

Portable, e.g. Pack 'n Play

Futon

Stroller

Queen

U/K

Unknown crib type

Playpen/other play

Swing

Bassinet

structure, not a portable crib

Bouncy chair

Bed side sleeper

Couch

Other, specify:

Chair

U/K

g. Child in a new or different environment than usual?
Yes

No

If futon,

Yes

Couch position
U/K

h. Child last placed to sleep with a pacifier?

U/K

Bed position

No

i. Child wrapped or swaddled in blanket?

U/K

Yes

If yes, describe why:
j. Child overheated?

U/K

If yes, describe:
Yes

If yes, outside temp ____ degrees F

No

U/K
Check all that apply:

k. Child exposed to second hand smoke?
Room too hot, temp ____ degrees F
Too much bedding

Yes

No

If yes, how often:

Too much clothing
l. Child's face when found:

No

m. Child's neck when found:

n. Child's airway when found (includes
nose, mouth, neck and/or chest):

U/K
Frequently

U/K

Occasionally
If fully or partially obstructed, what was obstructed?

Down

Hyperextended (head back)

Nose

Chest compressed

Up

Hypoextended (chin to chest)

Unobstructed by person or object

Mouth

U/K

To left or right side

Neutral

Fully obstructed by person or object

Neck compressed

U/K

Turned

Partially obstructed by person or object

U/K

U/K

Page 18 of 25

If fully or partially obstructed, describe obstruction in detail:

o. Objects in child's sleep environment and relation to airway obstruction:
Present?

Objects:
Ye

No

U/K

If present, describe position of object:

If present, did object

Next

obstruct airway?

On top

Under

of child

child

Tangled

to child around child

U/K

Yes

No

UK

Adult(s)

If adult(s) obstructed airway, describe

Other child(ren)

relationship of adult to child (for

Animal(s)

example, biological mother):

Mattress
Comforter, quilt, or other
Fitted sheet
Thin blanket/flat sheet
Pillow(s)
Cushion
Boppy or U shaped pillow
Sleep positioner (wedge)
Bumper pads
Clothing
Crib railing/side
Wall
Toy(s)
Other(s), specify:
__________________
__________________

p. Was there a reliable, non-conflicting witness account of how the child was found?

Yes

q. Caregiver/supervisor fell asleep while feeding child?
Yes

No

U/K

s. Child sleeping on same
surface with person(s) or

Bottle

Breast

U/K

If yes, check all that apply:

same surface, check all that apply:

With adult(s): # _______

To feed
U/K

No

U/K

If yes, reasons stated for sleeping on

animal(s)?
No

U/K

Yes

If yes, type of feeding:

Yes

No

r. Child sleeping in the same room as caregiver/supervisor at time of death?

Adult obese:

# U/K
Yes

No

U/K

To soothe

With other children: # _______

# U/K

Children's ages: _________

Usual sleep pattern

With animal(s): # _______

# U/K

Type(s) of animal: ________

No infant bed available
Home/living space overcrowded
Other, specify:
U/K
t. Is there a scene re-creation photo available for upload?

Yes

No

If yes, upload here. Only one photo allowed.

Select photo that demonstrates position and location of child’s body and airway (nose, mouth, neck, and chest). Size must be less than 6 mb and in .jpg or .gif format.

I3.

WAS DEATH A CONSEQUENCE OF A PROBLEM WITH A CONSUMER PRODUCT?

Yes

No, go to I4

U/K, go to I4

a. Describe product and circumstances:

b. Was product used properly?
Yes

No

U/K

c. Is a recall in place?
Yes

No

d. Did product have safety label?
U/K

Yes

No

e. Was Consumer Product Safety Commission (CPSC) notified?

U/K

Yes
No, go to www.saferproducts.gov to report
U/K

I4.

DID DEATH OCCUR DURING COMMISSION OF ANOTHER CRIME?

Yes

No, go to I5

a. Type of crime, check all that apply:
Robbery/burglary

Other assault

Arson

Illegal border crossing

Interpersonal violence

Gang conflict

Prostitution

Auto theft

Sexual assault

Drug trade

Witness intimidation

Other, specify:

Page 19 of 25

U/K

U/K, go to I5

I5.

CHILD ABUSE, NEGLECT, POOR SUPERVISION AND EXPOSURE TO HAZARDS

a. Did child abuse, neglect, poor or absent

b. Type of child abuse, check all that apply:

c. For abusive head trauma, were

supervision or exposure to hazards cause

Abusive head trauma, go to I5c

or contribute to the child's death?

Chronic Battered Child Syndrome, go to I5e

Yes/probable

Beating/kicking, go to I5e

No, go to next section

Scalding or burning, go to I5e

Yes

Other, specify and go to I5h

Child neglect, go to I5f

U/K, go to I5e

check all that apply:

U/K

None
Crying
Toilet training

the child shaken?

Sexual assault, go to I5h

Child abuse, go to I5b

No

d. For abusive head trauma, was

Munchausen Syndrome by Proxy, go to I5e

U/K, go to next section
If yes/probable, choose primary reason:

e. Events(s) triggering child abuse,

there retinal hemorrhages?

Yes

Disobedience

No

U/K

Feeding problems

If yes, was there impact?
Yes

No

Domestic argument

U/K

Other, specify:

Poor/absent supervision, go to I5h

U/K

Exposure to hazards, go to I5g
f. Child neglect, check all that apply:

g. Exposure to hazards:

Failure to provide necessities

Exposure to hazards:

Food

h. Was poverty a factor?

Do not include child's own behavior.

Do not include child's own behavior.

Yes

No

Shelter

Hazard(s) in sleep environment

(including sleep position and surface

If yes, explain in

Other, specify:

(including sleep position and surface

sharing)

Narrative

Failure to provide supervision

sharing)

Fire hazard

Emotional neglect, specify:

Fire hazard

Unsecured medication/poison

Abandonment, specify:

Unsecured medication/poison

Firearm hazard

Failure to seek/follow treatment,

Firearm hazard

Water hazard

Water hazard

Motor vehicle hazard

If yes, was this due to religious or

Motor vehicle hazard

Maternal substance use during

cultural practices?

Other hazard, specify:

pregnancy

specify:

Yes

No

U/K

Hazard(s) in sleep environment

U/K

Other hazard, specify:

I6. SUICIDE
a. Child’s history. Check all that have ever applied:

b. Was the child ever diagnosed with any of the

None listed below

following? Check all that apply.

Involved in sports

None listed below

Involved in activities (not sports)

Anxiety spectrum disorder

Viewed, posted or interacted on social media

Depressive spectrum disorder

If yes, specify platform(s):

d. Did the child ever communicate any suicidal
thoughts, actions or intent?
Yes

premeditated?

History of running away

Disruptive, impulse control or conduct disorder

History of fearfulness, withdrawal or anxiety

Eating disorder

Yes

History of explosive anger, yelling or disobeying

Substance-related or addictive disorders
Other, specify:

Yes

U/K

When did death occur: ________

Preparatory behavior #__

Non-fatal attempt #__

Aborted attempt #__

U/K

U/K

U/K

self-harm, such as cutting or burning oneself?

c. Check all suicidal behaviors/attempts that ever applied:
Interrupted attempt #__

No

No

g. Did the child ever have a history of non-suicidal

None listed below

Yes

U/K

it would likely be observed and intervened by others?

If yes, specify relationship to child: ___________
Was death a suicide?

No

f. Did the death occur under circumstances where

History of head injury
Death of a peer, friend or family member

U/K

e. Was there evidence the death was planned or

Bipolar spectrum disorder

If yes, when was the last head injury? _________

No

If yes, with whom? _________

Yes
If yes

No

U/K

Reported to others

Other, specify:

Noted on autopsy

h. Warning signs (https://youthsuicidewarningsigns.org) w/in 30 days of death. Check all that apply: i. Child experienced a

j. Suicide was part of: Check all that apply.

None listed below

Expressed perceived burden on others

known crisis within

None listed below

A suicide pact

Talked about or made plans for suicide

Showed worrisome behavioral cues

30 days of the death?

A cluster

A murder-suicide

Expressed hopelessness about the future

or marked changes in behavior

Yes

A contagion, copy-cat or

Displayed severe/overwhelming

U/K

If yes, explain:

No

U/K

imitation

emotional pain or distress

I7. LIFE STRESSORS

Please indicate all stressors that were present for this child around the time of death.

a. Life stressors - Social/economic

b. Life stressors - Relationships (age 5 and over)

c. Life stressors - School

None listed below

Housing instability

None listed below

Argument with friends

Stress due to sexual

(age 5 and over)

Racism

Witnessed

Family discord

Bullying as a victim

orientation

None listed below

Discrimination

violence

Argument with parents/caregivers

Bullying as a perpetrator

Stress due to gender

School failure

Poverty

Pregnancy

Parents’ divorce/separation

Cyberbullying as a victim

identity

Pressure to succeed

Neighborhood discord

Pregnancy

Parents' incarceration

Cyberbullying as a perpetrator

Extracurricular activities

Job problems

scare

Argument with significant other

Peer violence as a victim

New school

Money problems

Breakup with significant other

Peer violence as a perpetrator

Other school problems

Food insecurity

Social discord

Isolation

Page 20 of 25

d. Life stressors - Technology (age 5+) e. Life stressors - Transitions (age 5 and over)

f. Life stressors - Trauma (age 5 and over)

None listed below

Release from juvenile justice facility

None listed below

None listed below

Release from hospital

End of school year/school break

Rape/sexual assault

Electronic gaming

Transition from any level of mental

Transition to/from child welfare

Previous abuse (emotional/physical)

Texting

health care to another (e.g. inpatien

system

Restriction of technology

to outpatient, inpatient to residential

Release from immigrant detention

g. Life stressors - Describe any other life stressors:

Social media

outpatient to inpatient, etc.)

center

(age 5 and over)

Stress/negative consequences due to:

Family/domestic violence

I8. COVID-19-RELATED DEATHS
a. For the 12 months before the child's death, did the family experience

c. Was the child exposed to COVID-19 within 14 days of death?

any disruptions or significant changes to the following?

Yes

Check all that apply:

If yes, describe:

None listed below

No

U/K

d. Select the one option that best describes the impact of COVID-19 on this child’s death:

School

COVID-19 was the immediate or underlying cause of death

Daycare

COVID-19 was diagnosed at autopsy or the child was suspected to have COVID-19

Employment

COVID-19 indirectly contributed to the death but was not the immediate or underlying

Social services (such as unemployment assistance, TANF, WIC)

cause of death

Living environment

The birthing parent contracted COVID-19 during pregnancy

Medical care

Other, specify:

Mental health or substance use/abuse care

COVID-19 had no impact on this child's death

Home-based services (non-child welfare)

U/K

Child welfare services

e. Did COVID-19 impact the team’s ability to conduct this fatality review?

Legal proceedings within criminal, civil, or family courts

Yes

Other

No

U/K

If yes, check all that apply:

U/K

Unable to obtain records

Describe:

Team members unable to attend review

b. For the 12 months before the child's death, did the child’s family live in

Remote reviews negatively impacted review process

an area with an official stay at home order?
Yes

No

Team leaders redirected to COVID-19 response

U/K

f. Did the child have medical evidence of a significant inflammatory syndrome (including for example

If yes, was the stay at home order in place at the time of the child’s death?
Yes

No

fever, laboratory evidence of inflammation, and involvement of two or more organs) requiring

U/K

hospitalization in the week before death?
If yes, was the child diagnosed with MIS-C?

Yes

No

U/K

Yes

No

U/K

J. PERSON RESPONSIBLE (OTHER THAN DECEDENT)
1. Did a person or persons other than the child
do something or fail to do something that

One

Two

One

about the person(s)?

Two

One

Two

Yes/probable

Child abuse

Exposure to hazards

Yes

No, go to Section K

Child neglect

Assault, not child abuse

No, go to Section K

U/K, go to Section K

Poor/absent

Other, specify:

supervision

U/K

4. Is person listed in a previous section?

5. Primary person(s) responsible for action(s): Select one for each person responsible.

Two

One

Two

One

Two

One

Two

Yes, biological mother, go to J17

Adoptive parent

Grandparent

Medical provider

Yes, biological father, go to J17

Stepparent

Sibling

Institutional staff

Yes, caregiver one, go to J17

Foster parent

Other relative

Babysitter

Yes, caregiver two, go to J17

Mother's partner

Friend

Licensed child care

Yes, supervisor, go to J19

Father's partner

Acquaintance

worker

Child's boyfriend or girlfriend

Other, specify:

Stranger

U/K

No

6. Person's age in years:
One

3. Did the team have information

second person, use column "Two." Describe acts in narrative.

caused or contributed to the death?

One

2. What act(s)? Enter information for the first person under "One" and if there is a

7. Person's sex:

Two

One
# Years
U/K

8. Person speaks and understands English?

Two

One

Two

9. Person on active military duty?
One

Two

Male

Yes

Yes

Female

No

No

U/K

U/K
If no, language spoken:

Page 21 of 25

U/K
If yes, specify branch: