Form A (EMS-63) "EMS First Responder Nj Protocol for Scene Investigations of Infant and Child Deaths" - New Jersey

What Is Form A (EMS-63)?

This is a legal form that was released by the New Jersey Department of Health - a government authority operating within New Jersey. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on January 1, 2012;
  • The latest edition provided by the New Jersey Department of Health;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form A (EMS-63) by clicking the link below or browse more documents and templates provided by the New Jersey Department of Health.

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Download Form A (EMS-63) "EMS First Responder Nj Protocol for Scene Investigations of Infant and Child Deaths" - New Jersey

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For Use by Emergency Medical Services Personnel and Police
NEW JERSEY PROTOCOL FOR SCENE INVESTIGATION
FORM A: EMS/FIRST RESPONDER
OF INFANT AND CHILD DEATHS
Name of Infant/Child
Date of Birth
Agency ID Number
SECTION A - CONTACT INFORMATION
Use military time when recording the sequence of events.
Name, Affiliation, Contact Number of First Responder:
Date/Time of Response:
Location of Event:
Name, Address, Contact Number of Parent/Caregiver(s):
Name, Address, Contact Number of Person Providing Information (if
other than parent/caregiver):
Primary Language of Parent/Caregiver(s):
Primary Language of Person Providing Information (if other than
parent/caregiver):
Time Last Seen Alive
Time Infant Discovered
Name, Address, Contact Number of Person Discovering Infant
SECTION B - BODY
Indicate if information was observed at the time of your responding to the call, assessed by interviewing the caregiver, or both.
Body
Observed at Time of Response to Call
Assessed by Interviewing Caregiver
Unknown
Was the infant/child moved?
Position infant/child placed to sleep
Position infant/child found
Describe rigor, livor, body temperature
by touch (warm, cool, hot) and time
taken. Describe surface markings
and/or injuries:
Was body wedged or pinned?
No
Yes-describe:
Any visible pressure crease on
face/neck?
No
Yes-describe:
Condition of nose/mouth:
Obstruction
Mucus
Vomit
Formula
Food
Froth
Bloody Secretion
Clear
Other
Describe any items checked:
Were any of the bedding contents by the
infant/child's head or face when found?
No
Yes-describe:
Was a pacifier in use?
No
Yes
If so, is the pacifier intact?
Any Recent Illness?
No
Yes-Describe:
Do not use the reverse side of any form.
[ ] Check if using a separate sheet for comments with name, date of birth and Agency ID Number.
NJ Protocol for Scene Investigation of Infant and Child Deaths 2006
EMS-63
JAN 12
For Use by Emergency Medical Services Personnel and Police
NEW JERSEY PROTOCOL FOR SCENE INVESTIGATION
FORM A: EMS/FIRST RESPONDER
OF INFANT AND CHILD DEATHS
Name of Infant/Child
Date of Birth
Agency ID Number
SECTION A - CONTACT INFORMATION
Use military time when recording the sequence of events.
Name, Affiliation, Contact Number of First Responder:
Date/Time of Response:
Location of Event:
Name, Address, Contact Number of Parent/Caregiver(s):
Name, Address, Contact Number of Person Providing Information (if
other than parent/caregiver):
Primary Language of Parent/Caregiver(s):
Primary Language of Person Providing Information (if other than
parent/caregiver):
Time Last Seen Alive
Time Infant Discovered
Name, Address, Contact Number of Person Discovering Infant
SECTION B - BODY
Indicate if information was observed at the time of your responding to the call, assessed by interviewing the caregiver, or both.
Body
Observed at Time of Response to Call
Assessed by Interviewing Caregiver
Unknown
Was the infant/child moved?
Position infant/child placed to sleep
Position infant/child found
Describe rigor, livor, body temperature
by touch (warm, cool, hot) and time
taken. Describe surface markings
and/or injuries:
Was body wedged or pinned?
No
Yes-describe:
Any visible pressure crease on
face/neck?
No
Yes-describe:
Condition of nose/mouth:
Obstruction
Mucus
Vomit
Formula
Food
Froth
Bloody Secretion
Clear
Other
Describe any items checked:
Were any of the bedding contents by the
infant/child's head or face when found?
No
Yes-describe:
Was a pacifier in use?
No
Yes
If so, is the pacifier intact?
Any Recent Illness?
No
Yes-Describe:
Do not use the reverse side of any form.
[ ] Check if using a separate sheet for comments with name, date of birth and Agency ID Number.
NJ Protocol for Scene Investigation of Infant and Child Deaths 2006
EMS-63
JAN 12
NEW JERSEY PROTOCOL FOR SCENE INVESTIGATION
FORM A: EMS/FIRST RESPONDER
OF INFANT AND CHILD DEATHS
Page 2
Name of Infant/Child
Date of Birth
Agency ID Number
SECTION C - HEAD AND NECK POSITION WHEN INFANT/CHILD WAS FOUND
Indicate if information was observed at the time of your responding to the call, assessed by interviewing the caregiver, or both.
Observed at Time of
Assessed by
Body
Unknown
Response to Call
Interviewing Caregiver
Extended (backward)
Flexed (chin toward chest)
Neutral (in line with spine)
Rotated (side)-describe:
If face down, any depression/pocket in
bedding?
No
Yes-describe:
SECTION D - RESUSCITATION / CPR
Indicate how caregiver reports they performed CPR (if applicable); record the manner, number of breaths or compressions provided.
Any resuscitation?
Duration:
Were parents/caregivers provided with pre-arrival
No
Yes-describe:
instructions from the 9-1-1 dispatcher?
Indicate by Whom:
No
Yes
Rescue Breaths
Mouth to Mouth
Mouth to Nose & Mouth
Compression Ratio
Method (check one)
finger tips
heel:
one hand
two hands
SECTION E - OTHER OBSERVATIONS
Did you observe any signs of trauma upon arrival?
Any witnessed trauma due to administering care (CPR, treatments, etc)?
No
Yes-describe:
No
Yes-describe:
Was child pronounced at the scene via telemetry?
No
Yes-If yes, provide pronouncing physician contact information:
Name:
Phone:
Time:
Address:
Was child brought to ED?
No
Yes-describe sequence:
SECTION F - ENVIRONMENT
Was scene disturbed (as reported by caregiver)?
Room temperature where found (thermostat):
No
Yes-describe:
Were windows/doors open when arriving at
Any odor(s)?
Any stains or secretions on bedding, clothing or
scene?
No
Yes-describe:
adults?
No
Yes-describe:
No
Yes-describe:
Signs of drug use?
Signs of alcohol use?
Signs of exposure to smoke (cigarette, other)?
No
Yes-describe:
No
Yes-describe:
No
Yes-if other, specify:
SECTION G - ITEMS COLLECTED
Check and describe all items collected:
Clothing
Diaper
Bedding
Defective Bed
Bottle/Formula
Food
Honey
Medications
Home Remedies
Suspected Poison
Hospital Records- Provide name of hospital:
Other:
Describe all items checked; indicate where items were taken and by whom:
Do not use the reverse side of any form.
[ ] Check if using a separate sheet for comments with name, date of birth and Agency ID Number.
NJ Protocol for Scene Investigation of Infant and Child Deaths 2006
EMS-63
JAN 12
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