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Mass Trauma > Response Tools > Rapid Assessment > Instrument 

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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#_______


___________ (24 hr)
Last Name: 
______ yrs    months
First Name: 
Sex:    M    F    No Data
Medical Record #:

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.

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This page last reviewed 08/04/04.

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