fatal_injury_surveillance_form
 Share
The version of the browser you are using is no longer supported. Please upgrade to a supported browser.Dismiss

View only
 
 
ABCDEFGH
1
typenamelabelhintappearancerelevantconstraintconstraint_message
2
3
todaytoday
4
deviceiddevice_id
5
phonenumberphone_number
6
7
begin groupgroup11
8
textfacility_name1.1 Facility Namew4
9
select_one facility_typefacility_type1.2 Facility Typew2 horizontal
10
integercase_id_number1.3 Case Identification Numberw2
11
datepostmortem_date1.4 Postmortem Exam Datew2
12
select_one yes_noautopsy_performed1.5 Internal Autopsy Performed?w2 horizontal
13
integerage1.6 Deceased Agew1
14
select_one age_unitsage_unitSelect age unitw1 horizontal
${age} <= 23 or ${age} = '' or . != 'months'
Enter age in years if older than 23 months.
15
select_one sexsex1.7 Deceased Sexw2 horizontal
16
end group
17
18
begin groupgroup22
19
datedate_injury2.1 Date of Injuryw2
20
datedate_death2.2 Date of Deathw2
21
end group
22
23
begin groupgroup33
24
select_one injury_placeinjury_place3.1 Place of Injury Occurrencew3 horizontal
25
textinjury_place_otherSpecify Other:w1
${injury_place} = 'other'
26
select_one death_placedeath_place3.2 Place of Death Occurrencew2 horizontal
27
textdeath_place_otherSpecify Other:w1
${death_place} = 'other'
28
end group
29
30
begin groupgroup44w5
31
select_one intentintent4.1 Apparent Intentw5 horizontal
32
select_one mechanismmechanism4.2 Mechanism of Injuryw5 horizontal
33
select_one transport_modetransport_modeMode of Transportw5 horizontal
${mechanism} = 'rti'
34
select_one counter_partcounter_partCounter Partw3 horizontal
${mechanism} = 'rti'
35
end group
36
37
begin groupgroup55
38
textnarrativeIncident 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
Loading...
Main menu