Centers for Disease Control and Prevention logo
 link to CDC Home link to search page link to Health Topics A-Z  
   
mass trauma preparedness and response--cdc's injury center  
 
Emergency Home  l  Injury Home  l  Mass Trauma Home  l  Contact Us  

 

Mass Trauma > Response Tools > Rapid Assessment > Instrument 

adobe acrobat reader symbol  PDF Version (Requires Acrobat Reader)

If this page does not refresh click here.

Mass Trauma Data Instrument

Related Links

 
  Explanatory Notes

  Rapid Assessment Overview  
  

The preferred format to use for actual data collection is the PDF. (Requires Acrobat Reader)

Abstractor_______________      Case#_______

 
Demographics
 
 

Facility: 
 
__________________________
Date:
 
____/_____/_____
Time:
 
___________ (24 hr)
 
Last Name: 
 
___________________________
 
DOB:
 
____/_____/_____
 
Age:
 
______ yrs    months
 
First Name: 
 
___________________________
 
Sex:    M    F    No Data
 
Medical Record #:
 
 ______________________
 
Other:
 
____________________________________

Circumstances of Injury

Reason for Visit:: ____________________________________________________________
 

How Did the Injury Happen? ____________________________________________


____________________________________________________________________________

 
What Was S/he Doing? _________________________________________________


____________________________________________________________________________

 
Where Did the Injury Occur? _____________________________________________

____________________________________________________________________

Was the Injury Caused by the Event?
       
Direct Effect     Indirect Effect   Not Event Caused   Uncertain    No Data


How Arrived:   Ambulance   Public Transportation   Private Vehicle

Walked/Carried   Other: ______________________   No Data



Summary Information

Injury Condition(s) (Check all that apply):
 

Amputation Crush Foreign Body Poisoning______________
Brain Injury (concussion) Cut/Open Wound/Bleeding Fracture Smoke Inhalation
Burn____% _____degree Drowning/Submersion Overexertion Sprain/Strain/Dislocation
Other:___________________________________ No Data Superficial (contusion/bruise)

Other Condition(s) (Check all that apply):
 

Abdominal Pain/ N / V / diarrhea Chest Pain Hearing Problem Psychological Problem
Altered Mental Status Eye/Vision Problem Neurologic Problem Rash
Breathing Problem Fever Pregnancy Other:__________________
No Data

 
Details of Conditions

  • Condition #1:_____________________________________________________ 
     
    Body Part(s):______________________________ 
     
  • Condition #2:_____________________________________________________

    Body Part(s):______________________________ 
      
  • Condition #3:_____________________________________________________
     
    Body Part(s):______________________________ 
     
  • Condition#4:_____________________________________________________
     
    Body Part(s):______________________________ 

 

Content last revised 3/10/03.
 


CDC Public Health Emergency Home   l   CDC Injury Home   l   Mass Trauma  l   Contact Us

CDC Home | CDC Search | Health Topics A-Z

Privacy Notice - Accessibility

This page last reviewed 08/04/04.

Centers for Disease Control and Prevention
National Center for Injury Prevention and Control