0920-1092 Att 2a_NFR-CRS-SDY Module I

I. OTHER CIRCUMSTANCES OF INCIDENT - ANSWER RELEVANT SECTIONS
I1. SUDDEN AND UNEXPECTED DEATH IN THE YOUNG (SDY) 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)
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	c. At any time more than 72 hours preceding death did the child have a personal
or symptoms within 72 hours prior to death?	history of any of the following chronic conditions or symptoms?
Symptom Present w/in 72 hours of death	Symptom Present more than 72 hours of death
Cardiac Yes No U/K	Cardiac	Yes No U/K
Chest pain	Chest pain
Dizziness/lightheadedness	Dizziness/lightheadedness
Fainting	Fainting
Palpitations	Palpitations
Neurologic	Neurologic
Concussion	Concussion
Confusion	Confusion
Convulsions/seizure	Convulsions/seizure
Headache	Head injury
Head injury	Respiratory
Respiratory	Difficulty breathing
Asthma	Other
Pneumonia Difficulty breathing Other Acute Symptoms	Other, specify:
	d. Did the child have any prior serious injuries (e.g. near drowning, car
Fever	accident, brain injury)?
Muscle aches/cramping	No U/K
Vomiting Other, specify:	If yes, describe:
e. Had the child in the past ever been diagnosed by a medical professional for the following? Condition Diagnosed Condition Diagnosed Condition Diagnosed
Blood disease Y N UNeurologic (continued) Y N U Sickle cell disease Neurodegenerative disease Sickle cell traitStroke/mini stroke/ Thrombophilia (clotting disorder) TIA-Transient Ischemic Cardiac Y N UAttack Abnormal electrocardiogram Central nervous system (EKG or ECG)infection (meningitis Aneurysm or aortic dilatation or encephalitis) Arrhythmia/arrhythmia syndrome Respiratory Y N U Cardiomyopathy Apnea Congenital heart disease Asthma Coronary artery abnormalityPulmonary embolism EndocarditisPulmonary hemorrhage Heart failureRespiratory arrest Heart murmur

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Diabetes
f. Did the child have any blood relatives (brothers, sisters, parents, aunts, uncles, cousins, grandparents or other more distant			g. Has any blood relative (siblings,
relatives) with the following diseases, conditions or symptoms?			parents, aunts, uncles, cousins,
Y N U Deaths			grandparents) had genetic
Sudden unexpected death before age 50			testing?
If yes, the type of event, which relative, and relative’s age at death (for example, brother at age 30 who died			Yes No U/K
in an unexplained motor vehicle accident (driver of car)): Heart Disease Y N U Symptoms			If yes, describe the test/gene
Heart condition/heart attack or stroke before age 50 Febrile seizures			tested, reason for testing, family
If yes, describe: Unexplained fainting			member tested, and results:
Aortic aneurysm or aortic rupture Other Diagnoses Arrhythmia (fast or irregular heart rhythm) Congenital deafness Cardiomyopathy Connective tissue disease Congenital heart diseaseMitochondrial disease Neurologic DiseaseMuscle disorder or muscular dystrophy			Was a gene mutation found?
Epilepsy or convulsions/seizureThrombophilia (clotting disorder) Other neurologic diseaseOther diseases that are genetic or run in families, specify:			Yes No U/K
h. In the 72 hours prior to death was the child taking any prescribed		k. Was the child taking any of the following substance(s) within 24 hours of death?
medication(s)? Yes No U/K		Check all that apply:
If yes, describe:		Over-the-counter medicineAlcohol Energy drinksIllegal drugs
i. Within 2 weeks prior to death had the child:	N/A Yes No U/K
Taken extra doses of prescribed medications		Caffeine Legalized marijuana
Missed doses of prescribed medications		Performance enhancers Other, specify:
Changed prescribed medications, describe:		Supplements Tobacco U/K
j. Was the child compliant with their prescribed medications?
N/A Yes No U/K If not compliant, describe why and how often:		If yes to any items above, describe:
l. Did the child experience any of the following stimuli at time of incident or within 24 hours of the incident? At incident Within 24 hrs of incident Stimuli Yes No U/K Yes No U/K Physical activityIf yes to physical activity, describe type of activity: Sleep deprivationAt incident Within 24 hours of incident Driving Visual/video game stimuli Emotional stimuli Auditory stimuli/startle Physical traumaOther specify: Other, specify:At incident Within 24 hours of incident

m. Was the child an athlete? N/A Yes No U/K If yes, type of sport: Competitive Recreational U/K If competitive, did the child participate in the 6 months prior to death? Yes No U/K
n. Did the child ever have any of the following uncharacteristic symptoms				o. For child age 12 or older, did the child receive a pre-participation exam
during or within 24 hours after physical activity? Check all that apply:				for a sport? N/A Yes U/K
Chest pain Palpitations				If yes:
Convulsions/seizure Shortness of breath/difficulty breathing				Was it done within a year prior to death? Yes No U/K
Dizziness/lightheadedness Other, specify:				Did the exam lead to restrictions for sports or otherwise?
Fainting U/K				Yes No U/K
If yes to any item, describe type of physical activity and extent of symptoms:				If yes, specify restrictions:
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 disorder? Age 0 (infant) through 20 years: U/K		r. What type(s) of seizures did the child have? Check all that apply: Non-convulsive Convulsive (grand mal seizure or generalized tonic-clonic seizure) Occur when exposure to strobe lights, video game, or flickering light (reflex seizure) U/K				t. How many seizures did the child have in the year preceding death? 0/never 2More than 3 13U/K
q. What were the underlying cause(s) of the child’s seizures? Check all that apply: Brain injury/trauma, Other acute illness or specify: injury other than Brain tumor epilepsy CerebrovascularOther, specify: Central nervous system infection U/K Developmental brain disorder Genetic/chromosomal Idiopathic or cryptogenic						u. Did treatment for seizures includ anti-epileptic drugs? U/K If yes, how many different types of antiepileptic drugs did the child 14 25 36	e take? More than 6 U/K
		s. Describe the child's epilepsy/seizures (not including the seizure at time of death). Check all that apply: Last less than 30 minutes Last more than 30 minutes (status epilepticus) Occur in the presence of fever (febrile seizure) Occur in the absence of fever Occur when exposed to strobe lights, video game, or flickering light (reflex seizure)
						v. Was night surveillance used? Yes No U/K
I2. ANSWER THIS ONLY IF CHILD IS UNDER AGE FIVE: Yes, go to I2a No, go to I2tU/K, go to I2a WAS DEATH RELATED TO SLEEPING OR THE SLEEP ENVIRONMENT+?
a. Incident sleep place: Adult bedRocking-inclinedIf adult bed, what type? If car seat, was car seat If crib, type:WaterbedsleeperTwin secured in seat of car? Not portable Futon Stroller Full Yes No U/K PortableCouchSwingQueen Unknown crib typeChairBouncy chairKing BassinetFloorOther, specify:Other, specify: Bed side sleeperCar seatU/KU/K Baby box
b. Child put to sleep: On back On stomach On side U/K	c. Child found: On back On stomach On side U/K		e. Usual sleep position: On back On stomach On side U/K		f. Was there any type of crib, portable crib or bassinet in home for child? Yes No U/K
d. Usual sleep place: Adult bedRocking-inclinedIf adult bed, what type? If crib, type:WaterbedsleeperTwinKing Not portableFutonStrollerFullOther, specify: PortableCouchSwingQueenU/K Unknown crib typeChairBouncy chair BassinetFloorOther, specify: Bed side sleeperCar seatU/K Baby box
g. Child in a new or different environment than usual? Yes No U/K If yes, describe why:		h. Child last placed to sleep with a pacifier? Yes No U/K			i. Child wrapped or swaddled in blanket when last placed? Yes No U/K If yes, describe:

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j. Child overheated? Yes No U/K				k. Child exposed to second hand smoke?
Check all that apply: Room too hot, temp ____ degrees F				Yes No U/K
Too much bedding				If yes, how often: Frequently U/K
Too much clothing				Occasionally
l. Child's face when found: Down Up To left or right side U/K	m. Child's neck when found: Hyperextended (head back) Hypoextended (chin to chest) Neutral Turned U/K	n. Child's airway when found (includesIf fully or partially obstructed, what was obstructed? nose, mouth, neck and/or chest):NoseChest compressed Unobstructed by person or objectMouthU/K Fully obstructed by person or objectNeck compressed Partially obstructed by person orIf fully or partially obstructed, describe obstruction in objectdetail: U/K
o. Objects in child's sleep environment and relation to airway obstruction: If present, describe position of object: If present, did object Objects: Present? On top Under Next Tangled obstruct airway? Yes No U/K of child child to child around child U/K Yes No UK Adult(s)If adult(s) obstructed Other child(ren)airway, describe relation- Animal(s)ship of adult to child (for Mattressexample, childbearing Comforter, quilt, or otherparent): Fitted sheet Thin blanket/flat sheet Pillow(s) Cushion Nursing or U shaped pillow Sleep positioner (wedge) Bumper pads Clothing Bottle Wearable monitor 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 No U/K
q. Caregiver/supervisor fell asleep while feeding child? Yes No U/K If yes, type of feeding: Bottle Breast U/K			r. Child sleeping in the same room as caregiver/supervisor at time of death? Yes No U/K
s. Child sleeping on same If yes, reasons stated for sleeping on If yes, check all that apply: surface with person(s) or same surface, check all that apply:With adult(s): # _______ animal(s)?To feedAdult obese: U/K Yes No U/K To soothe With other children: # _____ Children's ages: _________ Usual sleep patternWith animal(s): # _______ Type(s) of animal: ________ No infant bed availableU/K 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.

g. Select the one option that best describes the impact of COVID-19 on this child’s death:						h. Did COVID-19 impact the team’s ability to conduct this fatality review?
COVID-19 was the immediate or underlying cause of death						Yes No U/K
COVID-19 was diagnosed at autopsy or child was suspected to have COVID-19						If yes, check all that apply:
COVID-19 indirectly contributed to the death but was not the immediate or						Unable to obtain records
underlying cause of death						Team members unable to attend review
The childbearing parent contracted COVID-19, specify:						Remote reviews negatively impacted review process
Before pregnancy3rd trimester 1st trimesterAfter delivery 2nd trimesterU/K Other, specify: COVID-19 had no impact on this child's death U/K						Team leaders redirected to COVID-19 response
J. PERSON RESPONSIBLE (OTHER THAN DECEDENT) This section is skipped for fetal deaths+
1. Did a person or persons other than the		2. What act(s)? Enter information for the first person under "One" and if							3. Did the team have information
child do something or fail to do		there is a second person, use column "Two." Describe acts in narrative.							about the person(s)?
something that caused or contributed		One Two One Two							One Two
to the death?		Child abuse Exposure to hazards								Yes
Yes/probable		Child neglect Assault, not child abuse								No, go to K
No, go to K		Poor/absent Other, specify:
U/K, go to K		supervision U/K
4. Is person listed in a previous section?			5. Primary person(s) responsible for action(s): Select one for each person respo							nsible.
One Two			One Two		One Two				One	Two
Yes, childbearing parent, go to J17			Adoptive parent		Sibling					Medical provider
Yes, non-childbearing biological			Stepparent		Other relative					Institutional staff
parent, go to J17			Foster parent		Friend					Babysitter
Yes, caregiver one, go to J17			Parent's partner		Acquaintance					Licensed child care
Yes, caregiver two, go to J17			Grandparent		Child's boyfriend or					worker
Yes, supervisor, go to J19					girlfriend					Other, specify:
No					Stranger					U/K
6. Person's age in years:	7. Person's sex:			8. Person speaks and understands English?				9. Person on active military duty?
One Two	One Two			One Two				One Two
	Male			Yes				Yes
# Years	Female			No				No
U/K	U/K			U/K				U/K
				If no, language spoken:				If yes, specify branch:
10. Person(s) have history of	11. Person(s) have history of child			12. Person(s) have history of child				13. Person(s) have disability or chronic
substance abuse?	maltreatment as victim?			maltreatment as a perpetrator?				illness?
One Two	One Two			One Two				One Two
Yes	Yes			Yes				Yes
No	No			No				No
U/K	U/K			U/K				U/K
14. Person(s) have prior	15. Person(s) have history of intimate partner violence?						16. Person(s) have delinquent/criminal history?
child deaths?	One Two						One Two
One Two	Yes, as victim						Yes
Yes	Yes, as perpetrator						No
No	No						U/K
U/K	U/K
17. At the time of the incident, was the person asleep? One Two One Two If yes, select the most appropriate Night time sleep Yes description of the person's sleeping Day time nap, describe: No period at incident:Day time sleep (for example, person is night shift worker), describe: U/KOther, describe:

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