4 survey

O. M. B. 0925-0281
Exp. XX/XXXX

ARIC

Atherosclerosis Risk in Communities

EVENT ID:

CORONER / MEDICAL EXAMINER
FORM
C

FORM CODE:

LAST NAME:

O

R

VERSION: C

DATE: 05/22/07

INITIALS:

Public reporting burden for this collection of information is estimated to average 6-15 minutes per response, including the time for reviewing instructions,
searching existing data sources, gathering and maintaining the data needed, 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 currently 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: NIH,
Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-0281). Do not return the completed form
to this address.

INSTRUCTIONS: The Coroner/Medical Examiner Form is completed for each eligible out-of-hospital death that was identified as a coroner or medical examiner case
on the death certificate, and recorded as such on the Death Certificate Form. Event ID, Name (or Soundex code) must be entered above. Refer to this form's Q x Q
instructions for information on specific items. For multiple choice and "yes/no" questions, circle the letter corresponding to the most appropriate response. If a letter is
circled incorrectly, mark through it with an "X" and circle the correct response.

CORONER/MEDICAL EXAMINER FORM (CORC Screen 1 of 13)
1. Date of death from death certificate:

4.

Has an official coroner's or medical
examiner's report or another source
of information from the coroner's or

Month

Day

Year

medical examiner's office been located?
Yes ................ Y

2. Is the name of coroner's or medical examiner's office available?

No ................ N

Yes ............. Y

Go to Item 25,
Screen 13.

No ..…....... N
5.
If "Yes", Specify: ______________________________________

Was an autopsy performed as part of
the medical examiner (coroner)
investigation?
Yes .............. Y

3. Abstracting for:
Cohort ...........….. C
Surveillance ........ S

No .............. N

CORONER/MEDICAL EXAMINER FORM (CORC Screen 2 of 13)
6.

Did the coroner's report mention any
of the following as contributing to or
being present at death?

6.f.
Yes

No

a. Recent myocardial infarction ...........…………… Y

N

b. Coronary heart
disease/ischemic/atherosclerotic
heart disease (other than MI) .……………........ Y

N

c. Hypertensive heart disease .........………….……. Y

N

d. Valvular heart disease ...…………………........... Y

N

e. Other heart disease ……………………………... Y

N

Yes No
Recent cerebral
hemorrhage .........……..………………... Y N
g. Recent cerebral
infarction ........………………….……... Y

N

h. Recent cerebral
embolus ........………………….……..... Y

N

i. Recent subarachnoid
hemorrhage .........……………..……….. Y

N

j. Recent stroke, other
or unspecified type .…………………….... Y

N

CORONER/MEDICAL EXAMINER FORM (CORC Screen 3 of 13)
7.a.

Yes No
7.e. Alcohol or drug
addiction ......…………….. Y N

Was any non-cardiac, non-stroke
finding mentioned as contributing
to death?
Yes ......... Y
No .......... N
Go to Item 8,
Screen 4

Yes

f. Epilepsy .........…………….. Y

N

g. Liver disease ....…………... Y

N

h. Other ......….....……….…... Y

N

No

b. Kidney disease ...…………………. Y

N

c. Chronic respiratory disease ............ Y
d. Psychiatric illness/depression .......... Y

N
N

If Other is Yes, Specify:
_______________________________
_______________________________
_______________________________

CORONER/MEDICAL EXAMINER FORM (CORC Screen 4 of 13)
ID LABEL

8. Do you have the final diagnoses?
┌────────────────────────────────────────────────────────── Yes
│
│
No
└── Specify:

Y
N

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CORONER/MEDICAL EXAMINER FORM (CORC Screen 5 of 13)
9. Pick one of the
following (A,B*,C*,D*,U*):

Patient died suddenly and was
known to have no acute symptoms ....… B

Patient had acute symptoms (cardiac
or non-cardiac) which led to an overt
change in activity or to seeking medical care....……….. A

Patient was found dead with no
documentation of symptoms .......…… C
Patient had symptoms but they were
chronic (without change) or did
not lead to a change in activity
or seeking medical care ..........……… D
Unknown ...........................…………. U
Go to Item 11.a,
Screen 7.

CORONER/MEDICAL EXAMINER FORM (CORC Screen 6 of 13)
10. Within 3 days of death or just
before death, did any of the
following symptoms begin for
the first time?
Yes No Unknown
a. Shortness of breath .......... Y N
U
b. Dizziness.…………......... Y

N

U

c. Palpitations .…………... Y

N

U

d. Marked or increased
fatigue, tiredness
or weakness ..…………. Y

N

U

e. Headache ......………... Y

N

U

f. Sweating ....…………... Y

N

U

Yes No Unknown
10.g. Paralysis ....……. Y N
U
h. Loss of speech ….. Y

N

U

i. Attack of
indigestion
or nausea or
vomiting......…….... Y

N

U

j. Other .........……….. Y

N

U

If other is Yes, Specify:
______________________________
_______________________________

CORONER/MEDICAL EXAMINER FORM (CORC Screen 7 of 13)
11.a. Was there an acute episode(s)
11.c. Did the patient take or
of pain or discomfort anywhere
was he/she given nitrates
in the chest, left arm or
shoulder or jaw either just
at the time of the acute
before death or within
episode?
72 hours of death?
Yes ......…….... Y

Yes ……....... Y

No .........……. N

No .……....... N

Unknown ....... U

Unknown ..... U

Go to Item 12
Screen 8.

d. Was the discomfort or
pain diagnosed as
having a non-cardiac
origin?

b. Did this pain or discomfort
specifically involve the chest?

Yes ....……... Y

Yes ...……....... Y

No .....……... N

No ….............. N

Unknown ..... U

Unknown ........ U

If "Yes", Specify:
___________________________

CORONER/MEDICAL EXAMINER FORM (CORC Screen 8 of 13)
12. Place of death (circle only one):
Home (or other private
residence) ......…......……...

13.a. Did anyone witness the death?
Yes ..........…………. Y
A

No .........…………... N

Work .................…………... B

Unknown .…………. U

In a public building .....……. C

Go to Item 15a
Screen 10.

On a bus or public
transportation ....….....……. D
On the street .......…....……

E

b. Do you have the name and
address for this witness?

In an automobile .........……

F

Yes ............ Y

In nursing home ..........…… G

No .............. N

In emergency room ....……. H

If "Yes", Specify:

In an ambulance .........……. I

Name:

_________________________________

In hospital ..........…....…….

J

Address: _______________________________

Other ....................………

O

_______________________________

Unknown .................…….. U

CORONER/MEDICAL EXAMINER FORM (CORC Screen 9 of 13)
13.c. Relationship of this witness to
deceased:

14. Time from onset of acute
symptoms to death (or time
since last known to be

Spouse .........…...... S

alive if no known acute

Parent ...........……. P

symptoms) (Choose only one):

Daughter/Son ........ C

5 minutes or less ......………….... A

Other Relative ...... R

More than 5 minutes
to 1 hour ……………………...... B

Friend ............…… F

More than 1 hour
to 24 hours ....….……………...... C

Workmate ............ W
Other .............…... O

More than 24 hours ....………...... D

Unknown ............. U

Unknown ..........……………........ U

CORONER/MEDICAL EXAMINER FORM (CORC Screen 10 of 13)
15.a. Is there a history of a myocardial
infarction prior to the onset of
this event?

15.c. Was the deceased hospitalized
for the MI?
Yes .......………... Y

Yes .........……... Y
No ..........…….… N
No .............…… N
Unknown ..…...... U
Unknown .......... U
Go to Item 16
Screen 11.

b. Did an MI occur within four weeks
prior to this event?
Yes .............. Y

Go to Item 16
Screen 11.

d. Do you know the name of the
hospital?
Yes .....…….….... Y
No ......………..... N

No .............……………….. N

If "Yes", Specify:

Unknown ……………….... U

_____________________________________

Go to Item 16
Screen 11.

CORONER/MEDICAL EXAMINER FORM (CORC Screen 11 of 13)
16. Is there any history of angina pectoris
or coronary insufficiency?
Yes .............……... Y

18. Is there a history of valvular disease
or cardiomyopathy?
Yes ..……............ Y
..

No ..........……...... N

No .…….............. N

Unknown ............. U

Unknown ............ U

17. Is there a history of any other chronic
ischemic heart disease?

19. Is there a history of coronary bypass
surgery prior to this event?

Yes ..........……...... Y

Yes .........…........ Y

No ...........……...... N

No ....……........... N

Unknown .............. U

Unknown ............ U

CORONER/MEDICAL EXAMINER FORM (CORC Screen 12 of 13)
20. Is there a history of coronary
angioplasty prior to this event?
Yes ..........…....... Y
No ............……... N
Unknown ............ U
21.a. Is there a history of stroke
prior to this event?
Yes ............…….. Y
No ..........……..... N
Unknown ............ U

22. Is there a history of hypertension
(high blood pressure) prior to this
event?
Yes ...……...... Y
No .……......... N
Unknown ....... U
a. Is there a history
of diabetes?
Yes ........…… Y
No ........….…. N
Unknown ....... U

Go to Item 22

b. Did a stroke occur within four
weeks prior to this event?
Yes ....……....... Y
No .......……..... N
Unknown ......... U

b. Is there a history
of smoking?
Yes .....……... Y
No .....…….... N
Unknown ...... U

CORONER/MEDICAL EXAMINER FORM (CORC Screen 13 of 13)
23. Was the decedent taking any of the
following medications as an outpatient
within the four weeks prior to death?
Yes No Unknown
a. Nitrates ...……..... Y N U

24. Was this form completed by abstraction
or by interview with the coroner?
Abstraction .............. A
Interview ..…............ I

b. Calcium channel
blockers ....……... Y N U
25. Abstractor Number:
c. Beta-blockers ….. Y N U
d. Digitalis .....……. Y N U
e. ACE or angiotensin II
inhibitors ... ……… Y N U
f. Aspirin .......……. Y N U

26. Date abstract completed:
Month

Day

Year