2 Coroner-Medical Examiner

The Jackson Heart Study: Annual Follow-up with Third Party Respondents

Attach 12 -Coroner-Medical Examiner (COR) Form

Jackson Heart Study Physicians

OMB: 0925-0491

Document [doc]
Download: doc | pdf

CORONER / MEDICAL EXAMINER FORM

OMB# 0925-0491

Expiration Date XX/XXXX



FORM CODE:


ID NUMBER: VERSION: C DATE: 05/22/07




LAST NAME: INITIALS:

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:



Month Day Year




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


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

No ..…....... N


If "Yes", Specify: ______________________________________




3. Abstracting for:

Cohort ...........….. C

Surveillance ........ S


4. Has an official coroner's or medical

examiner's report or another source

of information from the coroner's or

medical examiner's office been located?


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

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





5. Was an autopsy performed as part of

the medical examiner (coroner)

investigation?


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


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?

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

6.f. 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. Was any non‑cardiac, non‑stroke finding mentioned as contributing to death?

Yes ......... Y

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

Go to Item 8, Screen 4


Yes No


b. Kidney disease ...…………………. Y N


c. Chronic respiratory disease ............ Y N

d. Psychiatric illness/depression .......... Y N

Yes No

7.e. Alcohol or drug

addiction ......…………….. Y N


f. Epilepsy .........…………….. Y N


g. Liver disease ....…………... Y N


h. Other ......….....……….…... Y 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 Y

No N

└── Specify:


____________________________________________________________________________________


____________________________________________________________________________________


____________________________________________________________________________________


____________________________________________________________________________________


____________________________________________________________________________________


____________________________________________________________________________________


____________________________________________________________________________________


____________________________________________________________________________________

____________________________________________________________________________________


____________________________________________________________________________________


____________________________________________________________________________________


____________________________________________________________________________________


____________________________________________________________________________________


____________________________________________________________________________________


____________________________________________________________________________________


____________________________________________________________________________________


____________________________________________________________________________________


____________________________________________________________________________________

CORONER/MEDICAL EXAMINER FORM (CORC Screen 5 of 13)

9. Pick one of the

following (A,B*,C*,D*,U*):


Patient had acute symptoms (cardiac

or non‑cardiac) which led to an overt

change in activity or to seeking medical care....……….. A


Patient died suddenly and was

known to have no acute symptoms ....… B

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

U nknown ...........................…………. 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)

of pain or discomfort anywhere

in the chest, left arm or

shoulder or jaw either just

before death or within

72 hours of death?

Yes ......…….... Y

No .........……. N

Unknown ....... U

Go to Item 12 Screen 8.



b. Did this pain or discomfort

specifically involve the chest?

Yes ...……....... Y

No ….............. N

Unknown ........ U


11.c. Did the patient take or

was he/she given nitrates

at the time of the acute

episode?


Yes ……....... Y


No .……....... N


Unknown ..... U


d. Was the discomfort or

pain diagnosed as

having a non-cardiac

origin?

Yes ....……... Y

No .....……... N

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) ......…......……... A


Work .................…………... B


In a public building .....……. C


On a bus or public

transportation ....….....……. D


On the street .......…....…… E


In an automobile .........…… F


In nursing home ..........…… G


In emergency room ....……. H


In an ambulance .........……. I


In hospital ..........…....……. J


Other ....................……… O


Unknown .................…….. U

13.a. Did anyone witness the death?

Yes ..........…………. Y

No .........…………... N


Unknown .…………. U

Go to Item 15a Screen 10.





b. Do you have the name and

address for this witness?

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

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

If "Yes", Specify:


Name: _________________________________


Address: _______________________________

_______________________________

CORONER/MEDICAL EXAMINER FORM (CORC Screen 9 of 13)

13.c. Relationship of this witness to

deceased:


Spouse .........…...... S


Parent ...........……. P


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


Other Relative ...... R


Friend ............…… F


Workmate ............ W


Other .............…... O


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

14. Time from onset of acute

symptoms to death (or time

since last known to be

alive if no known acute

symptoms) (Choose only one):


5 minutes or less ......………….... A

More than 5 minutes

to 1 hour ……………………...... B

More than 1 hour

to 24 hours ....….……………...... C

More than 24 hours ....………...... D


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?


Yes .........……... Y

No .............…… N

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


b. Did an MI occur within four weeks

prior to this event?


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


No .............……………….. N

Unknown ……………….... U


15.c. Was the deceased hospitalized

for the MI?


Yes .......………... Y


No ..........…….… N

Unknown ..…...... U

Go to Item 16 Screen 11.



d. Do you know the name of the

hospital?


Yes .....…….….... Y

No ......………..... N

If "Yes", Specify:


_____________________________________






CORONER/MEDICAL EXAMINER FORM (CORC Screen 11 of 13)

16. Is there any history of angina pectoris

or coronary insufficiency?


Yes .............……... Y


No ..........……...... N


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



17. Is there a history of any other chronic

ischemic heart disease?


Yes ..........……...... Y


No ...........……...... N


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


18. Is there a history of valvular disease

or cardiomyopathy?


Yes ..……............ Y

..

No .…….............. N


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



19. Is there a history of coronary bypass

surgery prior to this event?


Yes .........…........ Y


No ....……........... N


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

Go to Item 22


b. Did a stroke occur within four

weeks 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


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


b. Calcium channel

blockers ....……... Y N U


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

24. Was this form completed by abstraction

or by interview with the coroner?



Abstraction .............. A


Interview ..…............ I




25. Abstractor Number:



26. Date abstract completed:

Month Day Year




File Typeapplication/msword
File TitleARIC
AuthorCSCC
Last Modified Bypandeym
File Modified2009-12-15
File Created2009-11-10

© 2024 OMB.report | Privacy Policy