fatal_injury_surveillance_form

	A	B	C	D	E	F	G	H
1	type	name	label	hint	appearance	relevant	constraint	constraint_message

2
3	today	today
4	deviceid	device_id
5	phonenumber	phone_number
6
7	begin group	group1	1
8	text	facility_name	1.1 Facility Name		w4
9	select_one facility_type	facility_type	1.2 Facility Type		w2 horizontal
10	integer	case_id_number	1.3 Case Identification Number		w2
11	date	postmortem_date	1.4 Postmortem Exam Date		w2
12	select_one yes_no	autopsy_performed	1.5 Internal Autopsy Performed?		w2 horizontal
13	integer	age	1.6 Deceased Age		w1
14	select_one age_units	age_unit	Select age unit		w1 horizontal		${age} <= 23 or ${age} = '' or . != 'months'	Enter age in years if older than 23 months.
15	select_one sex	sex	1.7 Deceased Sex		w2 horizontal
16	end group
17
18	begin group	group2	2
19	date	date_injury	2.1 Date of Injury		w2
20	date	date_death	2.2 Date of Death		w2
21	end group
22
23	begin group	group3	3
24	select_one injury_place	injury_place	3.1 Place of Injury Occurrence		w3 horizontal
25	text	injury_place_other	Specify Other:		w1	${injury_place} = 'other'
26	select_one death_place	death_place	3.2 Place of Death Occurrence		w2 horizontal
27	text	death_place_other	Specify Other:		w1	${death_place} = 'other'
28	end group
29
30	begin group	group4	4		w5
31	select_one intent	intent	4.1 Apparent Intent		w5 horizontal
32	select_one mechanism	mechanism	4.2 Mechanism of Injury		w5 horizontal
33	select_one transport_mode	transport_mode	Mode of Transport		w5 horizontal	${mechanism} = 'rti'
34	select_one counter_part	counter_part	Counter Part		w3 horizontal	${mechanism} = 'rti'
35	end group
36
37	begin group	group5	5
38	text	narrative	Incident Summary Narative	Describe the cause, nature and circumstances of the injury (from the autopsy report, police records, and/or bystander reports).	multiline
39	end group