Trauma Data Collection Form
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1
2TRAUMA DATA COLLECTION FORM
(To be completed in Accident and Emergency (Casualty), Crisis Care Centres and Mortuaries)
Institute
___________________________
District/subdistrict __________________
Hospital No.
_____________________
SAPS Case No.
__________________
h
m
Date of incident
d
d
m
m
y
y
y
y
Time
Date of admission
d
d
m
m
y
y
y
y
Time
h
m
Date of discharge
d
d
m
m
y
y
y
y
Time
h
m
Date of death
d
d
m
m
y
y
y
y
Time
h
m
Patient profile
Gender
M
F
Population group
Black
White
Coloured
Asian
Age group
1
0-11 months
4
10-19 years
7
40-49 years
10
70-79 years
2
1 – 5 years
5
20-29 years
8
50-59 years
11
80-89 years
3
6 – 9 years
6
30-39 years
9
60-69 years
12
> 90 years
Method of reaching institute
1
Ambulance
3
Other law enforcer
5
Private transport
7
Other (specify)
2
Police
4
Walk-in
6
Public transport
Place where incident occurred
1
Agricultural area
8
Flat
15
N’club / Disco
22
School
2
Amusement centre
9
Hospital
16
National road
23
Sea / beach
3
Banking institution
10
Hotel
17
Private house
24
Ship / boat
4
Bar / shebeen
11
Industrial area
18
Public transport
25
University / Tech
5
Clinic / CHC
12
Informal settlement
19
Railway
26
Other (specify)
6
Commercial area
13
Major / main road
20
River / dam / lake
7
Detention / prison
14
Motor vehicle
21
Road / street
Geographical location where incident occurred
1
City / town / urban area
District
Subdistrict
2
Rural area / countryside
3
At sea
4
In aircraft
Yes
No
Unknown
Alcohol or drug use prior to incident
1
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