Commonwealth of Pennsylvania s7

COMMONWEALTH OF PENNSYLVANIA Department of Human Services

SUBJECT: CHILD FATALITY/NEAR FATALITY DATA COLLECTION FORM

TO: Department of Human Services – Office of Children, Youth and Families – ChildLine and Abuse Registry, Via Docushare FROM: [Name], Individual Completing the Form

DATE: [Date Form Sent to ChildLine and Abuse Registry]

FATALITY NEAR FATALITY DATE OF INCIDENT: CWIS REFERRAL ID: DATE OF INITIAL REPORT: REGION: COUNTY: COUNTY CASE # AND/OR CASE NAME: INVESTIGATING WORKER NAME: STATUS OF INVESTIGATION

Pending Criminal Court Pending Juvenile Court Unfounded Indicated Founded Action (PCC) Action (PJC) COUNTY CHILD FATALITY AND NEAR FATALITY REVIEW TEAM: Planned Completed Date of Review: DATE OF DEATH, IF CHILD: DATE OF BIRTH: APPLICABLE: GENDER: M F ETHNICITY: Yes, Hispanic or Latino RACE: White Black or African American Not Hispanic or Latino American Indian or Alaskan Native Asian Unable to Determine Native Hawaiian or Other Pacific Islander Unable to determine Unknown or Missing HEIGHT: WEIGHT: LIVING ARRANGEMENT OF CHILD AT THE TIME OF FATALITY / NEAR FATALITY: Both Parents, Marital Status Unknown Married Parents Unmarried Parents Married Parent and Step Parent Parent and Cohabitating Partner Single Parent, Father & Other Adult Single Parent, Father Only Single Parent, Mother & Other Adult Single Parent, Mother Only Foster Care - Non relative/kin Foster Care - Relative/kin Informal Relative/kin Caretaker Permanent Legal Guardianship Supervised Independent Living Group Home Residential Facility Other Setting (Specify): Unknown INDIVIDUAL CHILD FACTORS (CHECK ALL THAT APPLY) Intellectual Disability Alcohol Abuse Emotionally Disturbed Illegal Drug Abuse Previous Placement Prescription Drug Abuse Problems in School Visually or Hearing Impaired o Academic Learning Disability o Behavioral Physically Disabled o Truancy Behavior Problem o Expulsion/Suspensions Other Medical Condition o Other (Specify): Other (Specify):

1 Attachment C CHILD KNOWN TO OTHER COMMUNITY AGENCIES (CHECK ALL THAT APPLY) Child Care / Daycare Legal Services Drug & Alcohol Head Start / Early Intervention Housing Services Family Centers Pre-School Home-based Services Aging School K - 12 Mental / Behavioral Health Services Adult Probation/Parole o Special Education Psychiatric Services Juvenile Probation o Alternative Contractors to County CCYA Intellectual Disabilities Services o Home Schooled o Family Support Services Mental Health / Intellectual Disabilities o Cyber o Family Preservation Services Case Management o Enrolled/Not Attending o Placement Services Public Assistance Educational and Training Services o Adoption Services Rape Crisis Employment Services o Case Management Services Domestic Violence Family Planning Services Respite Care Services Healthcare Provider Pregnancy and Parenting Services Other (Specify):

IDENTIFY PROVIDER(S) & EXPLAIN SERVICE(S):

MANNER OF FATALITY (SELECT ONE PER CORONER’S PRELIMINARY OR FINAL FINDING) Preliminary Finding Final Finding Was Forensic Autopsy Completed: Yes No Natural Accident Homicide Suicide Pending Unable to Determine LOCATION OF INCIDENT Home of Biological Parent Home of Adoptive Parent Home of Caregiver Home of Relative, Neighbor or Friend Public Place School Child Care / Daycare Out of Home Placement (Specify): Other (Specify): Unknown ADDRESS OF INCIDENT: IF APPLICABLE, LOCATION OF DEATH: CAUSE OF FATALITY / NEAR FATALITY (CHECK ALL THAT APPLY) Beating Failure to Provide Child with Poisoning Shooting Biting Nutrition/Hydration Providing Alcohol Slapping/Striking Burning/Scalding Failure to Provide Child with Providing Drugs Stabbing Causing Dental Care Pushing Submerging Cutting Failure to Provide Medical Recklessness Throwing Deprivation Treatment/Care Repeated, Prolonged, or Unreasonably Dropping Hitting/Punching Egregious Failure to Restraining/Confining Drowning Interfering with Breathing Supervise Other: Exposing Kicking Scratching Exposure Murder/Suicide Shaking Failure to Act At Time of Incident was Alleged/Substantiated Perpetrator: Drug Impaired Absent Alcohol Impaired Impaired by Illness (Specify): Asleep Impaired by Disability (Specify): Distracted Other (Specify): FOR CASES OF ABUSIVE HEAD TRAUMA, BIRTH HOSPITAL NAME AND ADDRESS IF VICTIM IS UNDER THE AGE OF 3:

FOR CASES INVOLVING INFANTS UNDER ONE YEAR: During Pregnancy, did mother: Experience Medical Complications/Infections Experience Intimate Partner Violence Use Illicit Drugs o Infant Born Drug Exposed Misuse OTC or Prescription Drugs Heavy Alcohol Use o Infant Born with Fetal Alcohol Effects or Syndrome

2 Attachment C

PARENTS, CAREGIVERS, ALLEGED/SUBSTANTIATED PERPETRATOR(S) DEMOGRAPHICS (ADD ADDITIONAL SHEETS FOR EACH INDIVIDUAL AND ATTACH TO THE BACK) NAME: DATE OF BIRTH: GENDER: M F

RELATIONSHIP TO CHILD: LENGTH OF Administrator Grandparent-Unknown Partial Program Staff RELATIONSHIP TO Adult Friend of Family Great Grandparent-Adoptive Peer CHILD: Advocate Great Grandparent-Maternal Physician Agency with Custody Great Grandparent-Paternal Physician’s Assistant Aunt-Adoptive Great Grandparent-Unknown Principal Aunt-Paternal Guardian Ad Litem Probation/Parole Officer Aunt-Unknown Guardian-Legal Psychiatrist/Psychologist Babysitter Guardian-Non-Legal Relative-Other BSC/Mobile Therapist Guardian-Unknown Residential Facility Staff Camp Employee Guidance Counselor Respite Care Provider ChildCare Volunteer In-Home Service Provider School Staff-Other Child Care Worker Kin Sibling-Adoptive Clergy Kinship Provider Sibling-Full Coach-Recreational Landlord Sibling-Maternal Half Coach-School Law Enforcement Sibling-Paternal Half Counselor Mother-Adoptive Sibling-Step Cousin-Adoptive Mother-Biological Sibling-Unknown Cousin-Maternal Mother-Step SPLC Cousin-Paternal Mother-Unknown Teacher Cousin-Unknown Neighbor Therapist Day Care Staff Nephew (of Subject Child) TSS Worker Dentist Niece (of Subject Child) Uncle-Adoptive Emergency Services Personnel Nurse/RN/LPN Uncle-Maternal Ex-Paramour of Parent Other Uncle-Paternal Father-Adoptive Other Public/Private Social Uncle-Unknown Father-Biological Service Agency Staff Unknown-Non CPSL Father-Legal Paramour of Parent Perpetrator Father—Step Paramour of Victim Unknown Father-Unknown Parent-Ex Unrelated Grandparent-Adoptive Parent-Ex-Step Unrelated Adult Grandparent-Maternal Parent-Foster Volunteer Grandparent-Paternal Grandparent-Step

ADDRESS: ETHNICITY: Yes, Hispanic or Latino RACE: White Black or African American Not Hispanic or Latino American Indian or Alaskan Native Asian Unable to Determine Native Hawaiian or Other Pacific Islander Unable to Determine Unknown or Missing EMPLOYMENT STATUS: EDUCATION LEVEL: MILITARY STATUS: Employed – Full Time Did Not Graduate High School Diploma or Equivalent Active Duty Employed – Part Time Technical, Business or Other Training Reserve Unemployed College / University National Guard Homemaker Graduate Level and Above Retired Unknown Unknown No Service

3 Attachment C INDIVIDUAL FACTORS (CHECK ALL THAT APPLY) Alcohol Abuse Domestic Violence (History of fighting between between parents Illegal Drug Abuse or caregivers) Prescription Drug Abuse Insufficient Family/Social Support Intellectual Disabilities Sexual Deviancy (Based on diagnoses or criminal convictions) Emotionally Disturbed Abused as a Child (History of reports of child abuse involving this Behavior Problem person as a child/victim) Visually or Hearing Impaired Impaired Judgment Learning Disability Marginal Parental Skills/Knowledge (Includes unrealistic Physically Disabled expectations, limited knowledge of childhood development, etc.) Other Medical Condition Criminal History Inadequate Housing Other (Specify): Financial Problems Public Assistance PRIOR CHILD DEATHS (CHECK ALL THAT APPLY): Parent/Caregiver Caused/Contributed If Yes, Manner (Check All That Apply): Natural Pending Homicide Unable to Determine Accident Other (Specify): Suicide Unknown INDIVIDUAL KNOWN TO OTHER COMMUNITY AGENCIES (CHECK ALL THAT APPLY) Child Care / Daycare Legal Services Drug & Alcohol Head Start / Early Intervention Housing Services Family Centers Pre-School Home-based Services Aging School K - 12 Mental / Behavioral Health Services Adult Probation/Parole o Special Education Psychiatric Services Juvenile Probation o Alternative Contractors to County CCYA Intellectual Disabilities Services o Home Schooled o Family Support Services Mental Health / Intellectual Disabilities Case o Cyber o Family Preservation Services Management o Enrolled/Not Attending o Placement Services Public Assistance Educational and Training Services o Adoption Services Rape Crisis Employment Services o Case Management Services Domestic Violence Family Planning Services Respite Care Services Healthcare Provider Pregnancy and Parenting Services Other (Specify):

4 Attachment C CHILDREN & YOUTH INVOLVEMENT

Child/Family Currently or Previously Known to Children and Youth: No Yes – If yes, check status and indicate opening and closing dates of service

Status of Involvement for Child/Family: Current Open File on Child/Family File Closed Within Past 12 Months File Closed Within Past 18 Months File Closed Within Past 24 Months File Closed Within Past 36 Months File Closed Within Past 48 Months File Closed Within Past 60 Months

OPENING / CLOSING DATES OF SERVICE FOR CHILD/FAMILY PRIOR TO INCIDENT:

Opening GPS Founded Causing Bodily Injury Closing Date: Subject Child: Date: CPS Indicated Medical Child Abuse Unfounded Causing or Substantially Contributing to Serious Mental Injury PCC Causing Sexual Abuse or Exploitation PJC Creating a Reasonable Likelihood of Bodily Injury Valid Creating a Likelihood of Sexual Abuse/Exploitation Invalid Causing Serious Physical Neglect Causing the Death Per Se Acts GPS Concerns LEO Opening GPS Founded Causing Bodily Injury Closing Date: Subject Child: Date: CPS Indicated Medical Child Abuse Unfounded Causing or Substantially Contributing to Serious Mental Injury PCC Causing Sexual Abuse or Exploitation PJC Creating a Reasonable Likelihood of Bodily Injury Valid Creating a Likelihood of Sexual Abuse/Exploitation Invalid Causing Serious Physical Neglect Causing the Death Per Se Acts GPS Concerns LEO Opening GPS Founded Causing Bodily Injury Closing Date: Subject Child: Date: CPS Indicated Medical Child Abuse Unfounded Causing or Substantially Contributing to Serious Mental Injury PCC Causing Sexual Abuse or Exploitation PJC Creating a Reasonable Likelihood of Bodily Injury Valid Creating a Likelihood of Sexual Abuse/Exploitation Invalid Causing Serious Physical Neglect Causing the Death Per Se Acts GPS Concerns LEO Date of Most Recent Risk/Safety Level of Risk/Safety Decision: Date of Most Recent Face to Face Contact with Child Prior to Incident:: Assessment Prior to Incident: By CCYA: Announced Unannounced Risk: Safety: Risk: Safety Decision: By Vendor: Announced Unannounced Number of Face to Face Contacts with Child Within Last Three Months Prior to Incident: By CCYA: By Vendor: ALL DATES INFORMATION OR REFERRALS RECEIVED NOT RESULTING IN AN ASSESSMENT/INVESTIGATION: Date and Reason: Date and Reason: Date and Reason:

5 Attachment C ALLEGED/SUBSTANTIATED PERPETRATOR INVOLVEMENT If Different From Above, Alleged/Substantiated Perpetrator Currently or Previously Known to Children and Youth: No Yes – If yes, check status and indicate opening and closing dates of service

Status of involvement for alleged/substantiated perpetrator: Current Open File File Closed Within Past 12 Months File Closed Within Past 18 Months File Closed Within Past 24 Months File Closed Within Past 36 Months File Closed Within Past 48 Months File Closed Within Past 60 Months

OPENING/CLOSING DATES OF SERVICE FOR ALLEGED/SUBSTANTIATED PERPETRATOR: Opening GPS Founded Causing Bodily Injury Closing Date: Subject Child: Date: CPS Indicated Medical Child Abuse Unfounded Causing or Substantially Contributing to Serious Mental Injury PCC Causing Sexual Abuse or Exploitation PJC Creating a Reasonable Likelihood of Bodily Injury Valid Creating a Likelihood of Sexual Abuse/Exploitation Invalid Causing Serious Physical Neglect Causing the Death Per Se Acts GPS Concerns LEO Opening GPS Founded Causing Bodily Injury Closing Date: Subject Child: Date: CPS Indicated Medical Child Abuse Unfounded Causing or Substantially Contributing to Serious Mental Injury PCC Causing Sexual Abuse or Exploitation PJC Creating a Reasonable Likelihood of Bodily Injury Valid Creating a Likelihood of Sexual Abuse/Exploitation Invalid Causing Serious Physical Neglect Causing the Death Per Se Acts GPS Concerns LEO Opening GPS Founded Causing Bodily Injury Closing Date: Subject Child: Date: CPS Indicated Medical Child Abuse Unfounded Causing or Substantially Contributing to Serious Mental Injury PCC Causing Sexual Abuse or Exploitation PJC Creating a Reasonable Likelihood of Bodily Injury Valid Creating a Likelihood of Sexual Abuse/Exploitation Invalid Causing Serious Physical Neglect Causing the Death Per Se Acts GPS Concerns LEO Date of Most Recent Risk/Safety Level of Risk/Safety Decision: Date of Most Recent Face to Face Contact with Perpetrator: Assessment Prior to Incident: By CCYA: Announced Unannounced Risk: Safety: Risk: Safety Decision: By Vendor: Announced Unannounced Number of Face to Face Contacts with Perpetrator Within the Last Three Months Prior to Incident: By CCYA: By Vendor: ALL DATES INFORMATION OR REFERRALS RECEIVED NOT RESULTING IN AN ASSESSMENT/INVESTIGATION: Date and Reason: Date and Reason: Date and Reason:

6 Attachment C Additional Details on History of Involvement:

DATE FORM RECEIVED CHILDLINE USE ONLY NAME OF PERSON WHO RECEIVED FORM CHILDLINE USE ONLY DATE FORM REVIEWED CHILDLINE USE ONLY

7 Attachment C