Form Detail Form Detail Form Detail Form

Form Approved
OMB NO. 0930-0276
Exp. Date: xx-xx-xxxx
Public Burden Statement: 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. The OMB control number for this project is 0930-0276. Public reporting burden for this collection of information is estimated to average 13 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. Send
comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to SAMHSA Reports Clearance Officer,
1 Choke Cherry Road, Room 7-1044, Rockville, Maryland, 20857.

Core Clinical Characteristics
(General Trauma Information Form)
Child ID Number:  -  - Child’s Initials:
Center ID

Subcenter ID

Child ID

First Middle Last

GENERAL TRAUMA INFORMATION
Please complete the following based on the client’s trauma history. This information should be maintained during treatment if trauma is experienced
or new trauma is revealed.

Trauma Type

Has child experienced
this trauma?
(Answer all Trauma
Types)

1.

Sexual maltreatment/abuse:
(Actual or attempted sexual molestation,
exploitation, or coercion by a caregiver)

0 = No
1 = Yes
2 = Suspected
99 = Unknown

2.

Sexual assault/rape:
(Actual or attempted sexual molestation,
exploitation, or coercion not by a caregiver
and not recorded as sexual abuse)

0 = No
1 = Yes
2 = Suspected
99 = Unknown

3.

Physical maltreatment/abuse:
(Actual or attempted infliction of physical
pain or bodily injury by a caregiver)

0 = No
1 = Yes
2 = Suspected
99 = Unknown

4.

Physical assault:
(Actual or attempted infliction of physical
pain or bodily injury not by a caregiver and
not recorded as physical abuse )

0 = No
1 = Yes
2 = Suspected
99 = Unknown

When was this type of trauma experienced?
Age in years:
(Check all ages that apply)
0

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

Unknown

This form is part of the Core Data Set designed for the National Child Traumatic Stress Initiative funded by SAMHSA based on NCTSN-General Information Form Trauma-CRF
Version 5.0 20080206.
ICF Macro 2010
Page 1

Child ID Number:  -  - 
Center ID

Subcenter ID

Core Clinical Characteristics
(General Trauma Information Form)

Child ID

GENERAL TRAUMA INFORMATION (CONTINUED)
Please complete the following based on the clients trauma history. This information should be maintained during treatment if trauma is experienced
or new trauma is revealed.

Trauma Type

Has child experienced
this trauma?
(Answer all Trauma
Types)

5.

Emotional abuse/Psychological
Maltreatment:
(Emotional abuse, verbal abuse, excessive
demands, emotional neglect)

0 = No
1 = Yes
2 = Suspected
99 = Unknown

6.

Neglect:
(Physical, medical, or educational neglect)

0 = No
1 = Yes
2 = Suspected
99 = Unknown

7.

Domestic Violence:
(Exposure to physical, sexual, and/or
emotional abuse directed at adult
caregiver(s) in the home)

0 = No
1 = Yes
2 = Suspected
99 = Unknown

8.

War/Terrorism/Political violence inside
the U.S.:
(Exposure to any of these events inside the
U.S.)

0 = No
1 = Yes
2 = Suspected
99 = Unknown

9.

War/Terrorism/Political violence outside
the U.S.:
(Exposure to any of these events outside of
the U.S.)

0 = No
1 = Yes
2 = Suspected
99 = Unknown

10. Illness/Medical Trauma:
(Life threatening or extremely painful
illness or medical procedure)

0 = No
1 = Yes
2 = Suspected
99 = Unknown

11. Serious injury/Accident:
(Unintentional accident or injury)

0 = No
1 = Yes
2 = Suspected
99 = Unknown

When was this type of trauma experienced?
Age in years:
(Check all ages that apply)
0

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

Unknown

This form is part of the Core Data Set designed for the National Child Traumatic Stress Initiative funded by SAMHSA based on NCTSN-General Information Form Trauma-CRF
Version 5.0 20080206.
ICF Macro 2010
Page 2

Child ID Number:  -  - 
Center ID

Subcenter ID

Core Clinical Characteristics
(General Trauma Information Form)

Child ID

GENERAL TRAUMA INFORMATION (CONTINUED)
Please complete the following based on the clients trauma history. This information should be maintained during treatment if trauma is experienced
or new trauma is revealed.

Trauma Type

Has child experienced
this trauma?
(Answer all Trauma
Types)

12. Natural disaster:
(Major accident or disaster that is the result
of a natural event)

0 = No
1 = Yes
2 = Suspected
99 = Unknown

13. Kidnapping:
(Unlawful seizure or detention against the
child’s will)

0 = No
1 = Yes
2 = Suspected
99 = Unknown

14. Traumatic loss or bereavement:
(Death or separation of a primary caregiver
or sibling; the unexpected, or premature
death of a close relative or close friend):

0 = No
1 = Yes
2 = Suspected
99 = Unknown

15. Forced displacement:
(Forced relocation due to political reasons)

0 = No
1 = Yes
2 = Suspected
99 = Unknown

16. Impaired Caregiver:
(History of exposure to caretaker
depression, other medical illness, or
alcohol/drug abuse)

0 = No
1 = Yes
2 = Suspected
99 = Unknown

17. Extreme interpersonal violence (not
reported elsewhere):
(e.g., Homicide/suicide)

0 = No
1 = Yes
2 = Suspected
99 = Unknown

18. Community violence (not reported
elsewhere):
(e.g., Gang-related violence, neighborhood
violence)

0 = No
1 = Yes
2 = Suspected
99 = Unknown

When was this type of trauma experienced?
Age in years:
(Check all ages that apply)
0

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

Unknown

This form is part of the Core Data Set designed for the National Child Traumatic Stress Initiative funded by SAMHSA based on NCTSN-General Information Form Trauma-CRF
Version 5.0 20080206.
ICF Macro 2010
Page 3

Child ID Number:  -  - 
Center ID

Subcenter ID

Core Clinical Characteristics
(General Trauma Information Form)

Child ID

GENERAL TRAUMA INFORMATION (CONTINUED)
Please complete the following based on the clients trauma history. This information should be maintained during treatment if trauma is experienced
or new trauma is revealed.

Trauma Type

Has child experienced
this trauma?
(Answer all Trauma
Types)

19. School violence (not reported elsewhere):
(e.g., School shooting, bullying, classmate
suicide)

0 = No
1 = Yes
2 = Suspected
99 = Unknown

20. Other Trauma (not reported elsewhere)?
Please Specify: _______________

0 = No
1 = Yes
2 = Suspected
99 = Unknown

When was this type of trauma experienced?
Age in years:
(Check all ages that apply)
0

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

Unknown

This form is part of the Core Data Set designed for the National Child Traumatic Stress Initiative funded by SAMHSA based on NCTSN-General Information Form Trauma-CRF
Version 5.0 20080206.
ICF Macro 2010
Page 4

Child ID Number:  -  - 
Center ID

Subcenter ID

Child ID

Core Clinical Characteristics
(General Trauma Information Form)

GENERAL TRAUMA INFORMATION (CONTINUED)
21. Primary focus of current treatment? (Select only one)
1 = Sexual maltreatment/abuse
2 = Sexual assault/rape
3 = Physical maltreatment/abuse
4 = Physical assault
5 = Emotional abuse/Psychological Maltreatment
6 = Neglect
7 = Domestic Violence
8 = War/Terrorism/Political violence inside the U.S.
9 = War/Terrorism /Political violence outside the U.S
10 = Illness/Medical Trauma
11 = Serious injury/Accident
12 = Natural Disaster
13 = Kidnapping
14 = Traumatic loss or bereavement
15 = Forced Displacement
16 = Impaired Caregiver
17 = Extreme interpersonal violence (not reported elsewhere)
18 = Community Violence (not reported elsewhere)
19 = School Violence (not reported elsewhere)
20 = Other Trauma (not reported elsewhere)

This form is part of the Core Data Set designed for the National Child Traumatic Stress Initiative funded by SAMHSA based on NCTSN-General Information Form Trauma-CRF
Version 5.0 20080206.
ICF Macro 2010
Page 5

Core Clinical Characteristics
(Trauma Detail Form)
Child ID Number:  -  - Child’s Initials:
Center ID

Subcenter ID

Child ID

First Middle Last

TRAUMA DETAIL, SEXUAL MALTREATMENT/ABUSE
Complete the following if experience of this trauma type is indicated on the General Trauma Information
Form.
1.

When was this trauma revealed/known (to the clinician)?

Baseline
Other, please provide date:  /  / 
Month

2.

Day

Year

Please describe the frequency of the experience. (Select only one)

1 = One-time event
2 = Repeated exposure
99 = Unknown
3.

Please describe the type(s) of experience. (Check all that apply)

Experienced
Witnessed
Vicarious
Unknown
4.

Please indicate the setting(s) of the experience. (Check all that apply)

Home
School
Community
Other, please specify: ____________________________
Unknown
5.

Please identify the perpetrator(s). (Check all that apply)

Parent
Other adult relative
Unrelated (but identifiable) adult
Sibling
Other youth
Stranger
Unknown

This form is part of the Core Data Set designed for the National Child Traumatic Stress Initiative funded by SAMHSA based on
NCTSN-Trauma Detail Form-CRF Version 5.0 20080206.
ICF Macro 2010
Page 6

Child ID Number:  -  - 
Center ID

Subcenter ID

Child ID

Core Clinical Characteristics
(Trauma Detail Form)

TRAUMA DETAIL, SEXUAL MALTREATMENT/ABUSE (CONTINUED)
6. Was serious injury inflicted?
0 = No
1 = Yes

If Yes: To whom? (Check all that apply)
Child
Parent
Other adult relative
Unrelated (but identifiable) adult
Sibling
Other youth
Other, please specify: ____________________________
99 = Unknown
7. Was a report filed? (e.g., Police, Child Protective Services)
0 = No
1 = Yes
99 = Unknown
8.

Did this maltreatment/abuse ever involve oral, vaginal, or anal penetration?
0 = No
1 = Yes
99 = Unknown

This form is part of the Core Data Set designed for the National Child Traumatic Stress Initiative funded by SAMHSA based on
NCTSN-Trauma Detail Form-CRF Version 5.0 20080206.
ICF Macro 2010
Page 7

Child ID Number:  -  - 
Center ID

Subcenter ID

Child ID

Core Clinical Characteristics
(Trauma Detail Form)

TRAUMA DETAIL, SEXUAL ASSAULT/RAPE
Complete the following if experience of this trauma type is indicated on the General Trauma Information
Form.
1.

When was this trauma revealed/known (to the clinician)?

Baseline
Other, please provide date:  /  / 
Month

2.

Day

Year

Please describe the frequency of the experience. (Select only one)

1 = One-time event
2 = Repeated exposure
99 = Unknown
3.

Please describe the type(s) of experience. (Check all that apply)

Experienced
Witnessed
Vicarious
Unknown
4.

Please indicate the setting(s) of the experience. (Check all that apply)

Home
School
Community
Other, please specify: ____________________________
Unknown
5.

Please identify the perpetrator(s). (Check all that apply)

Parent
Other adult relative
Unrelated (but identifiable) adult
Sibling
Other youth
Stranger
Unknown
6. Was serious injury inflicted?
0 = No
1 = Yes

If Yes: To whom? (Check all that apply)
Child
Parent
Other adult relative
Unrelated (but identifiable) adult
Sibling
Other youth
Other, please specify: ____________________________
99 = Unknown

This form is part of the Core Data Set designed for the National Child Traumatic Stress Initiative funded by SAMHSA based on
NCTSN-Trauma Detail Form-CRF Version 5.0 20080206.
ICF Macro 2010
Page 8

Child ID Number:  -  - 
Center ID

Subcenter ID

Child ID

Core Clinical Characteristics
(Trauma Detail Form)

TRAUMA DETAIL, SEXUAL ASSAULT/RAPE (CONTINUED)
7. Was a weapon used?
0 = No
1 = Yes
99 = Unknown
8. Was a report filed? (e.g. Police, Child Protective Services)
0 = No
1 = Yes
99 = Unknown
9.

Did this assault/rape ever involve oral, vaginal, or anal penetration?
0 = No
1 = Yes
99 = Unknown

This form is part of the Core Data Set designed for the National Child Traumatic Stress Initiative funded by SAMHSA based on
NCTSN-Trauma Detail Form-CRF Version 5.0 20080206.
ICF Macro 2010
Page 9

Child ID Number:  -  - 
Center ID

Subcenter ID

Child ID

Core Clinical Characteristics
(Trauma Detail Form)

TRAUMA DETAIL, PHYSICAL MALTREATMENT/ABUSE
Complete the following if experience of this trauma type is indicated on the General Trauma Information
Form.
1.

When was this trauma revealed/known (to the clinician)?

Baseline
Other, please provide date:  /  / 
Month

2.

Day

Year

Please describe the frequency of the experience. (Select only one)

1 = One-time event
2 = Repeated exposure
99 = Unknown
3.

Please describe the type(s) of experience. (Check all that apply)

Experienced
Witnessed
Vicarious
Unknown
4.

Please indicate the setting(s) of the experience. (Check all that apply)

Home
School
Community
Other, please specify: ____________________________
Unknown
5.

Please identify the perpetrator(s). (Check all that apply)

Parent
Other adult relative
Unrelated (but identifiable) adult
Sibling
Other youth
Stranger
Unknown
6. Was serious injury inflicted?
0 = No
1 = Yes

If Yes: To whom? (Check all that apply)
Child
Parent
Other adult relative
Unrelated (but identifiable) adult
Sibling
Other youth
Other, please specify: ____________________________
99 = Unknown

This form is part of the Core Data Set designed for the National Child Traumatic Stress Initiative funded by SAMHSA based on
NCTSN-Trauma Detail Form-CRF Version 5.0 20080206.
ICF Macro 2010
Page 10

Child ID Number:  -  - 
Center ID

Subcenter ID

Child ID

Core Clinical Characteristics
(Trauma Detail Form)

TRAUMA DETAIL, PHYSICAL MALTREATMENT/ABUSE (CONTINUED)
7. Was a weapon used?
0 = No
1 = Yes
99 = Unknown
8. Was a report filed? (e.g. Police, Child Protective Services)
0 = No
1 = Yes
99 = Unknown

This form is part of the Core Data Set designed for the National Child Traumatic Stress Initiative funded by SAMHSA based on
NCTSN-Trauma Detail Form-CRF Version 5.0 20080206.
ICF Macro 2010
Page 11

Child ID Number:  -  - 
Center ID

Subcenter ID

Child ID

Core Clinical Characteristics
(Trauma Detail Form)

TRAUMA DETAIL, PHYSICAL ASSAULT
Complete the following if experience of this trauma type is indicated on the General Trauma Information
Form.
1.

When was this trauma revealed/known (to the clinician)?

Baseline
Other, please provide date:  /  / 
Month

2.

Day

Year

Please describe the frequency of the experience. (Select only one)

1 = One-time event
2 = Repeated exposure
99 = Unknown
3.

Please describe the type(s) of experience. (Check all that apply)

Experienced
Witnessed
Vicarious
Unknown
4.

Please indicate the setting(s) of the experience. (Check all that apply)

Home
School
Community
Other, please specify: ____________________________
Unknown
5.

Please identify the perpetrator(s). (Check all that apply)

Parent
Other adult relative
Unrelated (but identifiable) adult
Sibling
Other youth
Stranger
Unknown
6. Was serious injury inflicted?
0 = No
1 = Yes

If Yes: To whom? (Check all that apply)
Child
Parent
Other adult relative
Unrelated (but identifiable) adult
Sibling
Other youth
Other, please specify: ____________________________
99 = Unknown

This form is part of the Core Data Set designed for the National Child Traumatic Stress Initiative funded by SAMHSA based on
NCTSN-Trauma Detail Form-CRF Version 5.0 20080206.
ICF Macro 2010
Page 12

Child ID Number:  -  - 
Center ID

Subcenter ID

Child ID

Core Clinical Characteristics
(Trauma Detail Form)

TRAUMA DETAIL, PHYSICAL ASSAULT (CONTINUED)
7. Was a weapon used?
0 = No
1 = Yes
99 = Unknown
8. Was a report filed? (e.g. Police, Child Protective Services)
0 = No
1 = Yes
99 = Unknown

This form is part of the Core Data Set designed for the National Child Traumatic Stress Initiative funded by SAMHSA based on
NCTSN-Trauma Detail Form-CRF Version 5.0 20080206.
ICF Macro 2010
Page 13

Child ID Number:  -  - 
Center ID

Subcenter ID

Child ID

Core Clinical Characteristics
(Trauma Detail Form)

TRAUMA DETAIL, EMOTIONAL ABUSE/PSYCHOLOGICAL MALTREATMENT
Complete the following if experience of this trauma type is indicated on the General Trauma Information
Form.
1.

When was this trauma revealed/known (to the clinician)?

Baseline
Other, please provide date:  /  / 
Month

2.

Day

Year

Please describe the frequency of the experience. (Select only one)

1 = One-time event
2 = Repeated exposure
99 = Unknown
3.

Please describe the type(s) of experience. (Check all that apply)

Experienced
Witnessed
Vicarious
Unknown
4.

Please indicate the setting(s) of the experience. (Check all that apply)

Home
School
Community
Other, please specify: ____________________________
Unknown
5.

Please identify the perpetrator(s). (Check all that apply)

Parent
Other adult relative
Unrelated (but identifiable) adult
Sibling
Other youth
Stranger
Unknown
6.

Please identify the type of maltreatment involved. (Check all that apply)

Emotional abuse
Emotional neglect
Verbal abuse
Excessive demands
Other, please specify: ____________________________
Unknown

This form is part of the Core Data Set designed for the National Child Traumatic Stress Initiative funded by SAMHSA based on
NCTSN-Trauma Detail Form-CRF Version 5.0 20080206.
ICF Macro 2010
Page 14

Child ID Number:  -  - 
Center ID

Subcenter ID

Child ID

Core Clinical Characteristics
(Trauma Detail Form)

TRAUMA DETAIL, NEGLECT
Complete the following if experience of this trauma type is indicated on the General Trauma Information
Form.
1.

When was this trauma revealed/known (to the clinician)?

Baseline
Other, please provide date:  /  / 
Month

2.

Day

Year

Please describe the frequency of the experience. (Select only one)

1 = One-time event
2 = Repeated exposure
99 = Unknown
3.

Please describe the type(s) of experience. (Check all that apply)

Experienced
Witnessed
Vicarious
Unknown
4.

Please indicate the setting(s) of the experience. (Check all that apply)

Home
School
Community
Other, please specify: ____________________________
Unknown
5.

Please identify the perpetrator(s). (Check all that apply)

Parent
Other adult relative
Unrelated (but identifiable) adult
Sibling
Other youth
Stranger
Unknown
6.

Please identify the type of neglect involved. (Check all that apply)

Physical
Medical
Education
Other, please specify: ____________________________
Unknown

This form is part of the Core Data Set designed for the National Child Traumatic Stress Initiative funded by SAMHSA based on
NCTSN-Trauma Detail Form-CRF Version 5.0 20080206.
ICF Macro 2010
Page 15

Child ID Number:  -  - 
Center ID

Subcenter ID

Child ID

Core Clinical Characteristics
(Trauma Detail Form)

TRAUMA DETAIL, DOMESTIC VIOLENCE
Complete the following if experience of this trauma type is indicated on the General Trauma Information
Form.
1.

When was this trauma revealed/known (to the clinician)?

Baseline
Other, please provide date:  /  / 
Month

2.

Day

Year

Please describe the frequency of the experience. (Select only one)

1 = One-time event
2 = Repeated exposure
99 = Unknown
3.

Please describe the type(s) of experience. (Check all that apply)

Experienced
Witnessed
Vicarious
Unknown
4.

Please indicate the setting(s) of the experience. (Check all that apply)

Home
Other, please specify: ____________________________
Unknown
5.

Please identify the perpetrator(s). (Check all that apply)

Parent
Other adult relative
Unrelated (but identifiable) adult
Sibling
Other youth
Stranger
Unknown
6. Was a weapon used?
0 = No
1 = Yes
99 = Unknown

This form is part of the Core Data Set designed for the National Child Traumatic Stress Initiative funded by SAMHSA based on
NCTSN-Trauma Detail Form-CRF Version 5.0 20080206.
ICF Macro 2010
Page 16

Child ID Number:  -  - 
Center ID

Subcenter ID

Child ID

Core Clinical Characteristics
(Trauma Detail Form)

TRAUMA DETAIL, DOMESTIC VIOLENCE (CONTINUED)
7. Was serious injury inflicted?
0 = No
1 = Yes

If Yes: To whom? (Check all that apply)
Child
Parent
Other adult relative
Unrelated (but identifiable) adult
Sibling
Other youth
Other, please specify: ____________________________
99 = Unknown
8. Was a report filed? (e.g. Police, Child Protective Services)
0 = No
1 = Yes
99 = Unknown

This form is part of the Core Data Set designed for the National Child Traumatic Stress Initiative funded by SAMHSA based on
NCTSN-Trauma Detail Form-CRF Version 5.0 20080206.
ICF Macro 2010
Page 17

Child ID Number:  -  - 
Center ID

Subcenter ID

Child ID

Core Clinical Characteristics
(Trauma Detail Form)

TRAUMA DETAIL, WAR/TERRORISM/POLITICAL VIOLENCE INSIDE U.S.
Complete the following if experience of this trauma type is indicated on the General Trauma Information
Form.
1.

When was this trauma revealed/known (to the clinician)?

Baseline
Other, please provide date:  /  / 
Month

2.

Day

Year

Please describe the frequency of the experience. (Select only one)

1 = One-time event
2 = Repeated exposure
99 = Unknown
3.

Please describe the type(s) of experience. (Check all that apply)

Experienced
Witnessed
Vicarious
Unknown
4.

Please indicate the type of weapons used. (Check all that apply)

Conventional (e.g. shootings, bombings, 9/11, Oklahoma City)
Chemical
Radiological
Biological
Unknown
5. Was anyone that the child knew seriously injured or killed?
0 = No
1 = Yes

If Yes: To whom? (Check all that apply)
Child
Parent
Other adult relative
Unrelated (but identifiable) adult
Sibling
Other youth
Other, please specify: ____________________________
99 = Unknown

This form is part of the Core Data Set designed for the National Child Traumatic Stress Initiative funded by SAMHSA based on
NCTSN-Trauma Detail Form-CRF Version 5.0 20080206.
ICF Macro 2010
Page 18

Child ID Number:  -  - 
Center ID

Subcenter ID

Child ID

Core Clinical Characteristics
(Trauma Detail Form)

TRAUMA DETAIL, WAR/TERRORISM/POLITICAL VIOLENCE OUTSIDE U.S.
Complete the following if experience of this trauma type is indicated on the General Trauma Information
Form.
1.

When was this trauma revealed/known (to the clinician)?

Baseline
Other, please provide date:  /  / 
Month

2.

Day

Year

Please describe the frequency of the experience. (Select only one)

1 = One-time event
2 = Repeated exposure
99 = Unknown
3.

Please describe the type(s) of experience. (Check all that apply)

Experienced
Witnessed
Vicarious
Unknown
4. Was anyone that the child knew seriously injured or killed?
0 = No
1 = Yes

If Yes: To whom? (Check all that apply)
Child
Parent
Other adult relative
Unrelated (but identifiable) adult
Sibling
Other youth
Other, please specify: ____________________________
99 = Unknown

This form is part of the Core Data Set designed for the National Child Traumatic Stress Initiative funded by SAMHSA based on
NCTSN-Trauma Detail Form-CRF Version 5.0 20080206.
ICF Macro 2010
Page 19

Child ID Number:  -  - 
Center ID

Subcenter ID

Child ID

Core Clinical Characteristics
(Trauma Detail Form)

TRAUMA DETAIL, ILLNESS/MEDICAL
Complete the following if experience of this trauma type is indicated on the General Trauma Information
Form.
1.

When was this trauma revealed/known (to the clinician)?

Baseline
Other, please provide date:  /  / 
Month

2.

Day

Year

Please describe the frequency of the experience. (Select only one)

1 = One-time event
2 = Repeated exposure
99 = Unknown
3.

Please describe the type(s) of experience. (Check all that apply)

Experienced
Witnessed
Vicarious
Unknown
4.

Please indicate the setting(s) of the experience. (Check all that apply)

Home
Hospital
Extended care facility
Other, please specify: ____________________________
Unknown
5. Was the child’s condition life threatening?
0 = No
1 = Yes
99 = Unknown

This form is part of the Core Data Set designed for the National Child Traumatic Stress Initiative funded by SAMHSA based on
NCTSN-Trauma Detail Form-CRF Version 5.0 20080206.
ICF Macro 2010
Page 20

Child ID Number:  -  - 
Center ID

Subcenter ID

Child ID

Core Clinical Characteristics
(Trauma Detail Form)

TRAUMA DETAIL, SERIOUS INJURY/ACCIDENT
Complete the following if experience of this trauma type is indicated on the General Trauma Information
Form.
1.

When was this trauma revealed/known (to the clinician)?

Baseline
Other, please provide date:  /  / 
Month

2.

Day

Year

Please describe the frequency of the experience. (Select only one)

1 = One-time event
2 = Repeated exposure
99 = Unknown
3.

Please describe the type(s) of experience. (Check all that apply)

Experienced
Witnessed
Vicarious
Unknown
4.

Please indicate the setting(s) of the experience. (Check all that apply)

Home
School
Community
Other, please specify: ____________________________
Unknown
5.

Please specify type of accident/injury(s). (Check all that apply)

Motor vehicle
Dog bite
Near drowning
Accidental shooting
Other, please specify: ____________________________
Unknown
6. Was permanent disability/death inflicted?
0 = No
1 = Yes

If Yes: To whom? (Check all that apply)
Child
Parent
Other adult relative
Unrelated (but identifiable) adult
Sibling
Other youth
Other, please specify: ____________________________
99 = Unknown

This form is part of the Core Data Set designed for the National Child Traumatic Stress Initiative funded by SAMHSA based on
NCTSN-Trauma Detail Form-CRF Version 5.0 20080206.
ICF Macro 2010
Page 21

Child ID Number:  -  - 
Center ID

Subcenter ID

Child ID

Core Clinical Characteristics
(Trauma Detail Form)

TRAUMA DETAIL, NATURAL DISASTERS
Complete the following if experience of this trauma type is indicated on the General Trauma Information Form.
1.

When was this trauma revealed/known (to the clinician)?

Baseline
Other, please provide date:  /  / 
Month

2.

Day

Year

Please describe the frequency of the experience. (Select only one)

1 = One-time event
2 = Repeated exposure
99 = Unknown
3.

Please describe the type(s) of experience. (Check all that apply)

Experienced
Witnessed
Vicarious
Unknown
4.

Please specify type of disaster(s) involved. (Check all that apply)

Earthquake
Hurricane
Flood
Tornado
Fire
Industrial
Other, please specify: ____________________________
Unknown
5. Was serious injury inflicted?
0 = No
1 = Yes

If Yes: To whom? (Check all that apply)
Child
Parent
Other adult relative
Unrelated (but identifiable) adult
Sibling
Other youth
Other, please specify: ____________________________
99 = Unknown
6. Did the child/family evacuate their home?
0 = No
1 = Yes
99 = Unknown
7. Was the child’s home severely damaged or destroyed?
0 = No
1 = Yes

99 = Unknown

This form is part of the Core Data Set designed for the National Child Traumatic Stress Initiative funded by SAMHSA based on
NCTSN-Trauma Detail Form-CRF Version 5.0 20080206.
ICF Macro 2010
Page 22

Child ID Number:  -  - 
Center ID

Subcenter ID

Child ID

Core Clinical Characteristics
(Trauma Detail Form)

TRAUMA DETAIL, KIDNAPPING/ABDUCTION
Complete the following if experience of this trauma type is indicated on the General Trauma Information
Form.
1.

When was this trauma revealed/known (to the clinician)?

Baseline
Other, please provide date:  /  / 
Month

2.

Day

Year

Please describe the frequency of the experience. (Select only one)

1 = One-time event
2 = Repeated exposure
99 = Unknown
3.

Please describe the type(s) of experience. (Check all that apply)

Experienced
Witnessed
Vicarious
Unknown
4.

Please identify the perpetrator(s). (Check all that apply)

Parent
Other adult relative
Unrelated (but identifiable) adult
Sibling
Other youth
Stranger
Unknown
5. Was a weapon used?
0 = No
1 = Yes
99 = Unknown

This form is part of the Core Data Set designed for the National Child Traumatic Stress Initiative funded by SAMHSA based on
NCTSN-Trauma Detail Form-CRF Version 5.0 20080206.
ICF Macro 2010
Page 23

Child ID Number:  -  - 
Center ID

Subcenter ID

Child ID

Core Clinical Characteristics
(Trauma Detail Form)

TRAUMA DETAIL, TRAUMATIC LOSS, OR BEREAVEMENT
Complete the following if experience of this trauma type is indicated on the General Trauma Information
Form.
1.

When was this trauma revealed/known (to the clinician)?

Baseline
Other, please provide date:  /  / 
Month

2.

Day

Year

Please describe the frequency of the experience. (Select only one)

1 = One-time event
2 = Repeated exposure
99 = Unknown
3.

Please describe the type(s) of experience. (Check all that apply)

Experienced
Witnessed
Vicarious
Unknown
4.

Please identify the people lost. (Check all that apply)

Parent
Other adult relative
Unrelated (but identifiable) adult
Sibling
Other youth
Stranger
Unknown
5. Was the loss/bereavement due to death?
0 = No
1 = Yes
99 = Unknown
6.

If loss was due to death, please specify cause(s) of death? (Check all that apply)

Natural causes/illness
Violence
Accident
Disaster
Terrorism, War, Political violence
Other, please specify: ____________________________
7. If loss is not due to death, was caregiver removed from home?
0 = No
1 = Yes
99 = Unknown

This form is part of the Core Data Set designed for the National Child Traumatic Stress Initiative funded by SAMHSA based on
NCTSN-Trauma Detail Form-CRF Version 5.0 20080206.
ICF Macro 2010
Page 24

Child ID Number:  -  - 
Center ID

Subcenter ID

Child ID

Core Clinical Characteristics
(Trauma Detail Form)

TRAUMA DETAIL, TRAUMATIC LOSS, OR BEREAVEMENT (CONTINUED)
8.

If caregiver(s) was removed from home, please specify reason(s). (Check all that apply)

Divorce
Incarceration
Hospitalization (medical or psychiatric)
Other, please specify: ____________________________
9. Was child removed from the home? (e.g., Foster care, other out-of-home)
0 = No
1 = Yes
99 = Unknown

This form is part of the Core Data Set designed for the National Child Traumatic Stress Initiative funded by SAMHSA based on
NCTSN-Trauma Detail Form-CRF Version 5.0 20080206.
ICF Macro 2010
Page 25

Child ID Number:  -  - 
Center ID

Subcenter ID

Child ID

Core Clinical Characteristics
(Trauma Detail Form)

TRAUMA DETAIL, FORCED DISPLACEMENT
Complete the following if experience of this trauma type is indicated on the General Trauma Information
Form.
1.

When was this trauma revealed/known (to the clinician)?

Baseline
Other, please provide date:  /  / 
Month

2.

Day

Year

Please describe the frequency of the experience. (Select only one)

1 = One-time event
2 = Repeated exposure
99 = Unknown
3.

Please describe the type(s) of experience. (Check all that apply)

Experienced
Witnessed
Vicarious
Unknown

This form is part of the Core Data Set designed for the National Child Traumatic Stress Initiative funded by SAMHSA based on
NCTSN-Trauma Detail Form-CRF Version 5.0 20080206.
ICF Macro 2010
Page 26

Child ID Number:  -  - 
Center ID

Subcenter ID

Child ID

Core Clinical Characteristics
(Trauma Detail Form)

TRAUMA DETAIL, IMPAIRED CAREGIVER
Complete the following if experience of this trauma type is indicated on the General Trauma Information
Form.
1.

When was this trauma revealed/known (to the clinician)?

Baseline
Other, please provide date:  /  / 
Month

2.

Day

Year

Please describe the frequency of the experience. (Select only one)

1 = One-time event
2 = Repeated exposure
99 = Unknown
3.

Please describe the type(s) of experience. (Check all that apply)

Experienced
Witnessed
Vicarious
Unknown
4.

Please identify the impaired caregiver(s). (Check all that apply)

Parent
Other adult relative
Unrelated (but identifiable) adult
Sibling
Other youth
Stranger
Other, please specify: ____________________________
Unknown
5.

The impairment was due to? (Check all that apply)

Drug use/abuse/addiction
Caregiver mental health impairment/disorder
Caregiver medical illness
Other, please specify: ____________________________
Unknown

This form is part of the Core Data Set designed for the National Child Traumatic Stress Initiative funded by SAMHSA based on
NCTSN-Trauma Detail Form-CRF Version 5.0 20080206.
ICF Macro 2010
Page 27

Child ID Number:  -  - 
Center ID

Subcenter ID

Child ID

Core Clinical Characteristics
(Trauma Detail Form)

TRAUMA DETAIL, EXTREME INTERPERSONAL VIOLENCE (NOT REPORTED ELSEWHERE)
Complete the following if experience of this trauma type is indicated on the General Trauma Information
Form.
1.

When was this trauma revealed/known (to the clinician)?

Baseline
Other, please provide date:  /  / 
Month

2.

Day

Year

Please describe the frequency of the experience. (Select only one)

1 = One-time event
2 = Repeated exposure
99 = Unknown
3.

Please describe the type(s) of experience. (Check all that apply)

Experienced
Witnessed
Vicarious
Unknown
4.

Please indicate the setting(s) of the experience. (Check all that apply)

Home
School
Community
Other, please specify: ____________________________
Unknown
5.

Please identify the perpetrator(s). (Check all that apply)

Parent
Other adult relative
Unrelated (but identifiable) adult
Sibling
Other youth
Stranger
Unknown
6.

Please indicate the type(s) of violence (Check all that apply)

Robbery
Assault
Homicide
Suicide
Other, please specify: ____________________________
Unknown
7. Was a weapon used?
0 = No
1 = Yes
99 = Unknown

This form is part of the Core Data Set designed for the National Child Traumatic Stress Initiative funded by SAMHSA based on
NCTSN-Trauma Detail Form-CRF Version 5.0 20080206.
ICF Macro 2010
Page 28

Child ID Number:  -  - 
Center ID

Subcenter ID

Child ID

Core Clinical Characteristics
(Trauma Detail Form)

TRAUMA DETAIL, EXTREME INTERPERSONAL VIOLENCE (NOT REPORTED ELSEWHERE)
(CONTINUED)
8. Was serious injury inflicted?
0 = No
1 = Yes

If Yes: To whom? (Check all that apply)
Child
Parent
Other adult relative
Unrelated (but identifiable) adult
Sibling
Other youth
Other, please specify: ____________________________
99 = Unknown

This form is part of the Core Data Set designed for the National Child Traumatic Stress Initiative funded by SAMHSA based on
NCTSN-Trauma Detail Form-CRF Version 5.0 20080206.
ICF Macro 2010
Page 29

Child ID Number:  -  - 
Center ID

Subcenter ID

Child ID

Core Clinical Characteristics
(Trauma Detail Form)

TRAUMA DETAIL, COMMUNITY VIOLENCE (NOT REPORTED ELSEWHERE)
Complete the following if experience of this trauma type is indicated on the General Trauma Information
Form.
1.

When was this trauma revealed/known (to the clinician)?

Baseline
Other, please provide date:  /  / 
Month

2.

Day

Year

Please describe the frequency of the experience. (Select only one)

1 = One-time event
2 = Repeated exposure
99 = Unknown
3.

Please describe the type(s) of experience. (Check all that apply)

Experienced
Witnessed
Vicarious
Unknown
4.

Please indicate the setting(s) of the experience. (Check all that apply)

School
Community
Other, please specify: ____________________________
Unknown
5. Was anyone seriously injured or killed?
0 = No
1 = Yes

If Yes: To whom? (Check all that apply)
Child
Parent
Other adult relative
Unrelated (but identifiable) adult
Sibling
Other youth
Other, please specify: ____________________________
99 = Unknown
6. Was the violence gang related?
0 = No
1 = Yes
99 = Unknown

This form is part of the Core Data Set designed for the National Child Traumatic Stress Initiative funded by SAMHSA based on
NCTSN-Trauma Detail Form-CRF Version 5.0 20080206.
ICF Macro 2010
Page 30

Child ID Number:  -  - 
Center ID

Subcenter ID

Child ID

Core Clinical Characteristics
(Trauma Detail Form)

TRAUMA DETAIL, SCHOOL VIOLENCE (NOT REPORTED ELSEWHERE)
Complete the following if experience of this trauma type is indicated on the General Trauma Information
Form.
1.

When was this trauma revealed/known (to the clinician)?

Baseline
Other, please provide date:  /  / 
Month

2.

Day

Year

Please describe the frequency of the experience. (Select only one)

1 = One-time event
2 = Repeated exposure
99 = Unknown
3.

Please describe the type(s) of experience. (Check all that apply)

Experienced
Witnessed
Vicarious
Unknown
4.

Please identify the type(s) of violence. (Check all that apply)

School shooting
Bullying
Classmate suicide
Other, please specify: ____________________________
Unknown
5. Was serious injury inflicted?
0 = No
1 = Yes

If Yes: To whom? (Check all that apply)
Child
Teacher/staff
Sibling
Other youth
Other, please specify: ____________________________
99 = Unknown

This form is part of the Core Data Set designed for the National Child Traumatic Stress Initiative funded by SAMHSA based on
NCTSN-Trauma Detail Form-CRF Version 5.0 20080206.
ICF Macro 2010
Page 31