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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

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│ No N

└── Specify:

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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 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