OMB No. XXXX-XXXX
Expiration Date: Month Year
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 XXXX-XXXX. Public reporting burden for this collection of information is estimated to average 2 minutes per client per year, 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 2-1057, Rockville, Maryland, 20857.
Patient ID:
Date of ED Admission:
Gender:
Age:
Ethnicity:
Diagnosis Code(s) (ICD-9 or ICD-10): _____________________________
Prior Suicide Attempt(s)? Yes No
7a. If yes, how many? _______
Discharged to:
Intensive Care Medical or Surgical Ward Inpatient Psychiatric Ward
Outpatient Psychiatric/MH/BH Treatment Community
Other (please specify): __________________________________
Prior ED admissions for suicide-related behavior? Yes No
9a. If yes, how many? _______
9b. For all suicide-related ED admissions within one year prior to the index admission, please provide:
Date of Admission: Diagnosis Code: Discharge Status:
i.
ii.
iii.
Subsequent ED admissions for suicide-related behavior? Yes No
10a. If yes, how many? _______
10b. For all suicide-related ED admissions within one year following the index admission, please provide:
Date of Admission: Diagnosis Code: Discharge Status:
i.
ii.
iii.
| File Type | application/msword |
| Author | Columbia University |
| Last Modified By | G Sgro |
| File Modified | 2015-03-22 |
| File Created | 2012-10-30 |