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Zip: Age (month, day, week, year): Age range (1-17): Male s/M/D Status: Alive Female s/M/D Status: Alive Birthplace of Infant: Infant s City: State: Zip: Date Infant was born: Infant is no longer alive: Yes No No/No/Not sure: Infant s Cause of Death: Cause of Death: Primary Residence of Infant: Location of Infant s Injury: Injury: Description of Infant s Occupational Exposure to Tobacco Products: Occupational Exposure to Alcohol and/or Drug Use: Occupational Exposure to Chemicals: Occupational Exposure to Occupational Health Hazards: Occupational Exposure to Poisoning: Occupational Exposure to Other Unsafe Contaminated Water: Sudden Unexplained Death Investigation Sudden Unexplained Infant Death Investigation SAID DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Disease Control and Prevention Division of Reproductive Health Maternal and Infant Health Branch Atlanta, Georgia 30333 Reporting Form INVESTIGATION DATA Infant s Last Name Infant s First Name Sex: Date of Birth: Race: White Middle Name Age: Black/African Am. Asian/Pacific Isl. Case Number SS#: Am.