5 survey

OMB# 0925-0491

EXPIRATION DATE XX/XXXX

COHORT EVENT ELIGIBILITY FORM

FORM CODE: C E L

VERSION E: 02/09/2007

ID NUMBER: CONTACT YEAR:

LAST NAME: INITIALS:

INSTRUCTIONS: This form should be completed for all Cohort deaths and hospitalizations, including every hospitalization reported from Annual Follow-Up. Assign an event ID number before completing this form, as all cohort events need an event ID number regardless of eligibility. Refer to this form's Q by Q instructions for information on entering numerical responses. For "multiple choice" and "yes/no" type questions, enter the letter corresponding to the most appropriate response.

A. IDENTIFYING INFORMATION

1. Last Name: ……………………………………………..

a. First Name: …………………………………………………………..

b. Middle Name:…………………………………………………………

Question 1c. deleted

2. Participant ID: ………………………………………………………………………..

Question 3 deleted

4. Date of discharge or death:…………………………………………….

Month Day Year

a. Date of birth:………………………………………………………………………..

Month Day Year

5. Source to identify event: …………………………………………………….. Cohort Annual Follow-up F

Surveillance Procedures S

Other O

6. Is this event a death? ……………………………………………………..………. Yes Y

Go to Item 8

No N

6.a. Was an autopsy performed? .................................................................. Yes Y

No N

7. Is this event an out-of-hospital death, or a death for

which hospitalization information cannot be located? ………………………………………. Yes Y

Go to Item 14a

No N

8. a. Hospital Code Number: ………………………………………………………………………………..

[If code 96-99, specify ]:

Hospital Name: ___________________________________

City and State: ___________________________________

b. Can information on this hospitalization be located? ……..………………………… Yes Y

Need for abstraction for this event cannot be determined, go to Item 15.a.

No N

B. INFORMATION FROM HOSPITAL DISCHARGE INDEX OR FACE SHEET

9. Hospital Record Number ………………………………………….

a. How has need for abstraction been established for

this cohort hospitalization?..............................................................Hospital Index I

Face Sheet F

Other O

[If eligibility is “O”, specify: _____________________________________________________ ]

10. Hospital discharge diagnosis and procedure codes (ICD-9 CODES):

a. . j. . s. .

b. . k. . t. .

c. . l. . u. .

d. . m. . . v. .

. .

e. . n. . w. .

f. . o. . x. .

g. . p. . y. .

h. . q. . z. .

i. . r. .

N

If Yes, then skip to 11b

OTE: 11a, 11a1, 11b, 11b1, 11f, 11f1 will be filled by DES when available.

1 1. a. Is a 402, 410-414, 427, 428, or 518.4 code listed? …………………………………Yes Y

No N

1 1. a. 1. Is a 00.50 - 00.54, 00.61-00.66, 35-39, 88.5, 89.49, 99.10 250, 390-459, ………. Yes Y

745-747, 794.3, 798, or 799 code listed? No N

11. a. 2. Are any of the following mentioned or suggested in the discharge summary? ………Yes Y

No N

Acute: MI Angina Chest Pain Ischemic Heart Disease

CHD Unstable Angina Cardiac Arrest Atherosclerotic Heart Disease

Or during this admission: CCU Care Nitroglycerin Cardiac Catheterization

CABG Elevated CK‑MB Coronary Angiography or Angioplasty

Thrombolytic therapy for coronary occlusion

If Yes, then skip to 11f

11. b. Is a 430-436 code listed? …………………………………. Yes Y

No N

1

If No, then skip to 11f

1.b.1 Is a 00.50 - 00.54, 00.61-00.66, 35-39, 88.5, 89.49,

99.10 250, 390-459, 745-747, 794.3, 798, or

799 code listed? ……………………………………………. ………… . Yes Y

No N

11. b.2. Are any of the following mentioned or suggested in the discharge summary? ............... Yes Y

No N

Acute: Stroke TIA Cerebral infarction Cerebrovascular disease

Aphasia Diplopia Cerebral embolus Lacunar (syndrome infarction)

Dysarthria Paralysis Cerebral hemorrhage Subarachnoid hemorrhage

Or during this admission: Carotid endarterectomy Cerebral angiography

CT/MRI scan showing cerebrovascular findings Carotid stent placement

Neuro ICU care [If in doubt, ask your surveillance MD.] Thrombolytic therapy for cerebral occlusion

1 1. f. Is a 398.91, 402.01, 402.11, 402.91, 404.01, 404.03, 404.11, 404.13, 404.91, 404.93,……………… Yes Y

415.0, 416.9, 425.4, 428, 518.4, 786.0 code listed?

No N

If Yes, and neither of 11a nor 11a2 is Yes, then , skip to 12. Or if Yes, and either of 11a or 11a2 is Yes, then skip to 15a.

11. f. 1. Is a 00.50 - 00.54, 00.61 -00.66, 35-39, 88.5, 89.49, 99.10, 250, 390-459, ……………… Yes Y

745-747, 794.3, 798, or 799 code listed?

No N

If No, and neither of 11a nor 11a2 is Yes, then skip to 12. Or if No, and either of 11a or 11a2 is Yes, then skip to 15a.

11.f.2. Are any of the following mentioned or suggested in the discharge summary?....... Yes Y

No N

Acute: Heart Failure Cardiomyopathy Orthopnea

Congestive Heart Failure (CHF) Ventricular Failure Paroxysmal nocturnal dyspnea

Pump Failure Impaired systolic function Cardiomegaly

Jugular venous distension (JVD) LV dysfunction (LVD)

Pulmonary Edema

Or during this admission: Heart Biopsy

Automatic Implantable Cardioverter Defibrillator (AICD) check

Implantation of cardiac resynchronization pacemaker (CRT)

If either of Items 11a or 11a2 is “Yes”, go to Item 15a. Otherwise, continue with Item 12.

If No, then skip to Item 15a. Screen 6.

12. Is this event an in-hospital death?…………………………………………..Yes Y

No N

C. INFORMATION FROM DEATH INDEX/CERTIFICATE

Question 13 deleted

14. a. ICD-10 CODE for underlying cause of death: ……………………………………. .

b. Is the Code E10 – E14, I10, I11, I20 – I25, I46 – I51, I70,

I97 (exclude I97.2), J81, J96, R96, R98, or R99? ………………………………… Yes Y

No N

(Automatically filled by DES)

D. Forms to Abstract

15. a. Needs hospitalized MI abstraction (CFD, CHI, HRA)………………………………………… Yes Y

(Automatically filled by DES: Y if 11a or 11a2 =Y, or if 14b = Y and 12 = Y, otherwise N) No N

15. b. Needs hospitalized stroke abstraction (CFD; copy materials for STR)………....…… ……. Yes Y

(Automatically filled by DES: Y if 11b or 11b.2 = Y, otherwise N) No N

15. c. Needs hospitalized HF abstraction (CFD, CHI, HFA)……..……………………………………… Yes Y

(Automatically filled by DES: Y if 11f or 11f.2 = Y, otherwise N) No N

15. d. Needs out-of-hospital death investigation (IFI, PHQ, DTH)……….……..…………………. Yes Y

(Automatically filled by DES: Y if 7 = Y and 14.b = Y, otherwise N) No N

15. e. Needs death certificate abstraction (DTH)………………..……………………………..……………Yes Y

(Automatically filled by DES: Y if Q6=Y) No N

15. f. Needs copy of autopsy report…………………………………………………………………….………Yes Y

(Automatically filled by DES: Y if 6.a.=Y and 15.a or b or c or d = Y) No N

16, 17, 18* Questions deleted *

19. a. Was this event reported in the corresponding

Annual Follow-Up for this participant? ………………………………………..…………………… Yes Y

No N

b. Contact year of corresponding Annual Follow-Up: ………………………………………………………………

3. Q uestion NUMBER from Version L or later of AFU form for the corresponding hospitalization.

For a previous version of AFU, a single LETTER will identify the AFU question. (if none, enter “ = =’’)

E. ADMINISTRATIVE INFORMATION

20. Date of data collection: …………………………………………………..

Month Day Year

21. Code number of person completing this form:……………………………………………………

CELE Version E 02-09-2007 5