Non-Fatal Injury Surveillance System
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1
2NON-FATAL INJURY SURVEILLANCE SYSTEM
DATE OF ENTRY:
DATA CLERK:
:
NAME OF HOSPITAL/FACILITY ………………………………
REGISTER #:
Case-definition: First time visit for an external cause of physical injury attended in ED
MODULE I – DEMOGRAPHIC INFORMATION
3. Parent’s Name
4.
1. Last Name
2.First Name
:
(for children <1)
Source of information
1.Self
2.Family/relatives
3.Other
5.Age
6.
8. Sex
9. Occupation or job title (paid work):
7
Date of birth
Birthday
.
(< 1 year)
Day
Month
Year
# months
# days
Other
M
F
Unk.
10. Education (highest year completed):
Town / City /Village
Region / State
11. Domicile
9. Unknown
FULL ADDRESS
12. Address
Town / City / Village
Region / State
9. Unknown
FULL ADDRESS
where the injury
occurred
MODULE II- GENERAL INFORMATION ABOUT THE INJURY EVENT
(CLOSE IN CIRCLES ) (For every variable check only one )
16.Event Type
17. Intent
18. Place
19. Activity
13. Day and Time of Event
(What were you doing when you
1- Unintentional*(
(
Where were you when you were
road traffic *, falls, burns,
DAY
MONTH
YEAR
14
Time
.
were injured?)
1-Isolated Event
injured?)
natural disasters)
1.1-Working (inside home)
(24 hour clock)
1-Home
2- Intentional- Interpersonal**
2-Natural
2-School/education area
1.2-Working (outside home)
3- Intentional- Self-directed***
3-Sport or recreation area
2-Educational activity
Disaster
4- Legal Intervention
15.
4-Street/highway
3-Organized Sports
5- War / Terrorism
1. Yes
2.No
9.Unkn.
5-Cafe,Bar or similar
Previous
3-War/Civil
4-Traveling
6-Farm
Visit?
9-Undetermined/ Unknown
Conflict
7-Trade or service area
5-Leisure or play
* If 1, then Road traffic event should be completed
8-Industrial/construction area
** If 2, then Interpersonal violence event should be
8-Other
4-Terrorism
completed
9-Body of water
If yes, Where:
9-Unknown
*** If 3, then Self-inflicted event should be completed
88-Other
8-Other
99-Unknown
9.
21.
20. Mechanism of injury (
1. Yes
2. No
Work-related injury
How was the injury sustained?)
Unk.
22. Type of industry
1-Road Traffic Injury
14-Exposure to extreme cold
corrosive substance
2-Sexual assault
15-Exposure to extreme pressure
22-Ingestion/poisoning: other
Describe:
_______________________________________
3-Fall/Push/Jump (same level)
16-
or unspecified
23. Size of workplace
24. Type of compensation
4-Fall/Push/Jump (higher level)
Hanging/strangulation/suffocation
23-Explosion from landmine
5-Blunt force
17-Drowning/submersion
24-Other explosive
1-Pay
6-Stab/Cut
18-Ingestion/poisoning by drugs
25-Bite from a person
1-Less than 5 persons
2-Other compensation
7-Gunshot w/ handgun
19-Ingestion/poisoning by
26-Bite from an animal
2-5 to 9 persons
8-Gunshot w/ rifle, shotgun, other
pesticides
27-Bite/Sting from an insect
(goods, etc)
3-10 to 50 persons
long gun
20-Ingestion/poisoning by gases
28-Electrocution
3-None
4-51 to 100 persons
9-Gunshot w/ other/unspecified firearm
or vapors
29-Neglect/Abandonment
5-Greater than 100 persons
10-Other projectile
21-Ingestion/poisoning from a
88-Other
11-Fire/smoke/flames
99-Unknown
12-Steam, hot vapors, hot objects
13-Exposure to extreme heat
MODULE III- SPECIFIC DATA ABOUT THE EVENT
(For every variable check only one)
SELF-DIRECTED VIOLENCE
ROAD TRAFFIC EVENTS
INTERPERSONAL VIOLENCE
31. Prior Attempt?
1.Yes
2.No
9.Unknown
25.
26.
27.
29
32. Precipitating Factors
.
Mode of
Person injured
Counterpart
Relationship of Perpetrator to the Victim
Transport
(What was the role of the injured
(What did the injured person collide
(Choose only one option)
(Choose primary cause)
person )
with?)
(How was the injured person
-Partner or ex-partner
1-Conflict with partner
1
-Pedestrian
1
traveling?)
2-Parent or step-parent
2-Conflict with family
1-Pedestrian
1-Pedestrian
2-Two or three wheel
3-Unrelated caregiver
3-Physical illness/problem
2-Motorcycle
2.1-Motorc./three wheel driver
motor vehicle
4-Other relative
2.1-Three wheel motor
2-2 Motorc./three w passenger
3-Car, pick-up, or van
4-Psychological condition
5-Friend / Acquaintance
vehicle
3-Driver of motor vehicle
4-Heavy transport vehicle,
5-Financial problems
6-Official/legal authorities
3-Private car
(car, bus, truck, taxi, etc)
bus
7-Unknown person (stranger)
6. Work problems
4-Pick-up or van
4-Passanger in motor vehicle
5-Rail vehicle, Train
8-Other
7-Legal system encounters
5-Heavy transport, bus
5-Passenger in back of truck
6-Other non-motor vehicle
9-Unknown (no information)
6-Other land transport
6-Pedal Cyclist
7-Animal cart
8-Death of family member
7-Pedal cycle
8.Driver/pass watercraft
8-Pedal cycle
9-Victim of sexual or physical abuse
30. Context
8-Watercraft
9-Rider of animal or animal
9-Non-collision transport
10-Difficulties with school
1-Family/Domestic violence
(
e.g. Intimate partner
9. Animal cart
cart
accident (thrown, fall,
violence, Child Maltreatment, Sexual Assault, Elder Abuse)
11-Unexpected pregnancy
10-Aircraft
88-Other
overturn)
2-Other interpersonal dispute
(e.g.
Gang-related,
11.Rail vehicle
99-Unknown
88-Other
88-Other _______________
conflict with peers, friends, neighbors)
88-Other
99-Unknown
99-Unknown
3-During a burglary, robbery or other crime
99-Unknown
8-Other____________
9-Unknown
1-Seat belt
2-Helmet
3. Reflective Vest
28. Safety Elements
4-Child car seat
5. Personal flotation device
(Circle more than one)
MODULE IV- ALCOHOL AND SUBSTANCE USE BY VICTIM/COUNTERPART
33. Alcohol use (Victim)
Clinical Observation
35. Other Psychoactive Substance Use (Victim)
36. Alcohol / Other Substance Use
(Counterpart/Perpetrator)
1- No suspicion or evidence
1-No suspicion or evidence
2-Yes, there is suspicion or evidence
1-No suspicion or evidence
2-Yes, there is suspicion, which one:
3-Yes, confirmed by Breath or Blood test
2-Yes, there is suspicion or evidence
____________________________________________
7-Not applicable
3-Yes, confirmed by Breath or Blood test
9-Unknown
7-Not applicable
7-Not applicable
34. Self-report: Did you drink alcohol 6 hours before
9- Unknown
9-Unknown
the injury event?
1. Yes __ 2. No __ 9. Unknown ___
MODULE V- CLINICAL DATA ABOUT THE INJURY
37. Nature of the Injury
38. Anatomic Location of the Injury
39. Severity
40. Disposition
1-Laceration, Abrasion
(You can circle more than one )
1-Treated and discharged
1-Minor or superficial
2-Cut / Wound / Bite
2-Transferred to hospital
1-Head
10-Pelvis /Genitals
(<1 hr tx; e.g. bruises, minor cuts)
3-Systemic Organ Injury
3-Admitted to the hospital
2-Face
11-Shoulder/Arm
2-Moderate
4-Refered to other facility
4-Strain/Sprain or Dislocation
(1-4 hrs tx; e.g. fractures, sutures)
3- Eyes
12-Elbow/Forearm
Which one?______________
5-Fracture
3–Severe
4- Ears
13-Wrist/Hand/Fingers
(>4hrs tx; e.g. internal
5-Left prior to discharge
6-Burn
5- Nose
14-Hip/Thigh
hemorrhage, punctured organs,
6-Discharged against advice
7-Bruise, Contusion
6- Neck
15-Knee/Legs
severed blood vessels)
7-Died on site/prior to discharge
8-Traumatic Brain Injury
7-Thorax (front and back)
16-Ankle/Feet/Toes
9-Unknown
88-Other________________
8-Back
17-Systemic
41. Preliminary Diagnosis (ICD codes):
99-Unknown
9-Abdomen
88-Other__________
42. Name of person who completes the form:
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