DRAFT Form Approved
OMB No. 0920-1108
Exp. Date 09/30/2022
Instructions for Paul Coverdell National Acute Stroke Program (PCNASP) Pre-Hospital Data Elements
Public reporting of this collection of information is estimated to average 30 minutes/hours per response, including the time for reviewing instructions and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a current valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to: CDC/ATSDR Reports Clearance Officer, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-1108).
Scene Arrival |
<ScnArrD> |
|
_ _/ _ _/ _ _ _ _ |
Date MMDDYYYY |
|
Required |
<ScnArrT> |
|
___: ____ |
Time HHMM |
|
Required |
|
Scene Departure |
<ScnDptD> |
|
_ _/ _ _/ _ _ _ _ |
Date MMDDYYYY |
|
Required |
<ScnDptT> |
|
___: ____ |
Time HHMM |
|
Required |
|
Patient Age |
<Age> |
Age |__|__|__| years |
Numeric ### = 3-digit |
0 < age < 125 |
Prepopulated from in-hospital data |
Required |
Patient Gender |
<Gender> |
Gender |
Numeric # = 1-digit |
1 - Male; 2 - Female; 3 - Unknown |
Select only 1 gender Prepopulated from in-hospital data |
Required |
Pre-hospital stroke screen performed |
<StkScn> |
Did EMS perform a pre-hospital stroke screen? |
Numeric # = 1-digit |
1 - Yes; 2– No; 3 – Not documented |
|
Required |
<EMSGlu> |
Glucose level |
Numeric # = 3-digit |
|
*GWTG: mg/dL; for glucometers that don’t produce a numeric value enter 600 for high and 20 for low |
Required |
File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
Author | Odom, Erika C. (CDC/ONDIEH/NCCDPHP) |
File Modified | 0000-00-00 |
File Created | 2022-02-04 |