Form 0920-1092 N SUID AND SDY CASE REGISTRY

CASE NUMBER
/ / / State / Team / ReviewYear of / Sequence ofReview	Case Type:  Death  Near death/serious injury  Not born alive (Fetal/stillborn)		Death Certificate Number: Birth Certificate Number: ME/Coroner Number:
			Date Team Notified of Death:
	 Child never left hospital following birth
N. SUID AND SDY CASE REGISTRY This section displays online based on your state's settings.
Section I1: OMB No. 0920-1092, Exp. Date: 9/30/2025 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 If yes, date of first Advanced Review meeting:		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:
4. Professionals at the Advanced Review meeting, check all that apply:  Cardiologist  Death investigator  Geneticist or genetic counselor  Pediatrician  CDR representative  Epileptologist  Mental health professional  Public health representative  Coroner  Forensic pathologist/medical examiner  Neonatologist  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  N/A  Yes  No  U/K
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?  N/A  Yes  No  U/K If no, why not?  Consent was not attempted  Consent was attempted but follow up was unsuccessful  Consent was attempted but family declined  Other, specify:
8. Was a specimen sent to the SDY Case Registry biorepository?  N/A  Yes  No  U/K
10. Categorization for SDY Case Registry (choose only one):  Excluded from SDY Case Registry  Explained neurological, specify:  Explained other, specify:  Unexplained, SUDEP  Incomplete case information  Explained infant suffocation  Unexplained, possible cardiac  Unexplained death  Explained cardiac, specify: (under age 1)  Unexplained, possible cardiac and SUDEP
11. Categorization for SUID Case Registry (choose only one):  Excluded (other explained causes, not suffocation) If possible suffocation or explained suffocation, select the primary  Unexplained: No autopsy or death scene investigation mechanism(s) leading to the death, check all that apply:  Unexplained: Incomplete case information  Soft bedding  Unexplained: No unsafe sleep factors  Wedging  Unexplained: Unsafe sleep factors  Overlay  Unexplained: Possible suffocation with unsafe sleep factors  Other, specify:  Explained: Suffocation with unsafe sleep factors