Section 2: Safe Infant (INTAKE) Case: (Case Name) Individual: Safe Infant (check all that apply) Birth related data Infant was left at: Premature Birth Police Station Difficult/problematic delivery Fire department Problems with pregnancy Hospital Pre-natal care EMS No pre-natal care Staffed place of worship Mother was physically abused during pregnancy No information Date Infant was left: Mother’s Information (check all that apply) Parent’s Medical Did the parent do one of the following before Diabetes or during the pregnancy? Allergies Smoke Asthma Use alcohol Seizures Use drugs or medication Cancer No information available Heart disease High blood pressure Mental illness Sexually transmitted disease Other No information available Father’s Information (check all that apply) Parent’s Medical Did the parent do one of the following before Diabetes or during the pregnancy? Allergies Smoke Asthma Use alcohol Seizures Use drugs or medication Cancer No information available
Section 2: Safe Infant (INTAKE) Case: (Case Name) Individual: Safe Infant (check all that apply) Birth related data Premature Birth Difficult/problematic delivery Problems with pregnancy Pre-natal care No pre-natal care Mother was physically abused during pregnancy No information Infant was left at: Police Station Fire department Hospital EMS Staffed place of worship Date Infant was left: Mother’s Information (check all that apply) Parent’s Medical Diabetes Allergies Asthma Seizures Cancer Heart disease High blood pressure Mental illness Sexually transmitted disease Other No information available Did the parent do one of the following before or during the pregnancy? Smoke Use alcohol Use drugs or medication No information available Father’s Information (check all that apply) Parent’s Medical Diabetes Allergies Asthma Seizures Cancer Did the parent do one of the following before or during the pregnancy? Smoke Use alcohol Use drugs or medication No information available
ADT%20Safe%20Infant%20Assessment.docx