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pdfCASE NUMBER 47-01-2021-00004
VT
/
Addison
/
State
/
Team
/
2021
Year of
Review
/
Case Type:
4
Sequence of
Review
/
Death
Near death/serious injury
Not born alive
(Fetal/stillborn)
Child never left hospital following birth
N. SUID AND SDY CASE REGISTRY
Death Certificate Number:
Birth Certificate Number:
ME/Coroner Number:
Date Team Notified of Death:
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Section I1: OMB No. 0920-1092, Exp. Date: 4/30/2022
Public reporting burden of this collection of information is estimated to average 10 minutes per response, including the time for reviewing instructions, searching existing data
sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not
required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect
of this collection of information, including suggestions for reducing this burden to: CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia
30333; ATTN: PRA (0920-1092)
1. Is this an SDY or SUID case?
Yes
No
If no, go to Section O
2. Did this case go to Advanced Review for the SDY Case Registry?
N/A
Yes
No
3. Notes from Advanced Review meeting (include case details that helped determine SDY
categorization and any ways to improve the review) or reason why case did not go to Advanced
Review:
If yes, date of first Advanced Review meeting:
4. Professionals at the Advanced Review meeting, check all that apply:
Cardiologist
CDR representative
Coroner
Death investigator
Epileptologist
Forensic pathologist/medical examiner
Geneticist or genetic counselor
Mental health professional
Neonatologist
Pediatrician
Public health representative
Others, specify:
5. Did the Advanced Review team believe the autopsy was
comprehensive?
Yes No U/K
6. If autopsy performed, did the ME/coroner/pathologist use the SDY Autopsy Guidance or Summary
7. Was a specimen saved for the SDY Case Registry?
N/A Yes No U/K
9. Did the family consent to have DNA saved as part of the SDY Case Registry?
8. Was a specimen sent to the SDY Case Registry biorepository?
N/A
Yes
No
N/A
Yes
No
U/K
N/A Yes No U/K
If no, why not? Consent was not attempted
U/K
Consent was attempted but follow up was unsuccessful
Consent was attempted but family declined
Other, specify:
10. Categorization for SDY Case Registry (choose only one):
Excluded from SDY Case Registry
Incomplete case information
Explained cardiac, specify:
Explained neurological, specify:
Explained infant suffocation
(under age 1)
Explained other, specify:
Unexplained, possible cardiac
Unexplained, possible cardiac
and SUDEP
Unexplained, SUDEP
Unexplained death
11. Categorization for SUID Case Registry (choose only one):
Excluded (other explained causes, not suffocation)
Unexplained: No autopsy or death scene investigation
Unexplained: Incomplete case information
Unexplained: No unsafe sleep factors
Unexplained: Unsafe sleep factors
Unexplained: Possible suffocation with unsafe sleep factors
Explained: Suffocation with unsafe sleep factors
If possible suffocation or explained suffocation, select the primary
mechanism(s) leading to the death,
check all that apply:
Soft bedding
Wedging
Overlay
Other, specify:
| File Type | application/pdf |
| File Modified | 2021-11-18 |
| File Created | 2021-11-18 |