Dialysis-related Cardiac Arrest Data Collection Tool for

Form Approved

OMB No. 0920-XXXX

Exp. Date XX/XX/2016

Dialysis–related Cardiac Arrest Data Collection Tool

To be used to obtain data from cased received through case finding (Epi X or professional list serve)

Date report received	__ __ / __ __ / __ __					CDC staff collecting information:__________
Report from	Name:_______________________Affiliation: ____________________________ State:__ __ Contact number:____________________________ Email:_________________________
Facility Name and location						LDO name (if known):___________________
Case information
Sex:	Male		Female AGE: _______ years Race/Ethnicity (*Check all that apply):_ American Indian/Alaska Native Asian Black or African American Hispanic or Latino _Native Hawaiian or Other Pacific Islander White___________________
Medical history	[ ] Stroke/CVD [ ] CAD [ ] Arrhythmia [ ] Allergy/anaphylaxis Other:___________________________________
Current medication	[ ] beta blockers [ ] ACEI [ ] ARB [ ] Diuretics [ ] CCB Other:________________________________________
Dialysis history	First dialysis date __ __/__ __/__ __ First dialysis at the clinic __ __/__ __/__ __
Access type	[ ] CVC [ ] AVF [ ] AVG [ ] Other_______________________
Event
Event Date:		__ __ / __ __ / __ __		Time __ __ : __ __ AM PM
Dialysis Start Time:		__ __ : __ __ AM PM			Stop time:		__ __ : __ __ AM PM
Symptoms/signs BEFORE event		[ ] Chest pain [ ] Palpitation [ ] Dyspnea [ ] Dizziness [ ] Wheezing [ ] Facial/lip swelling [ ] Hives/urticaria [ ] Pruritus Other:________________________________
Symptoms/signs AT TIME of event		[ ] Loss of consciousness [ ] Pulseless [ ] Hypotension [ ] Chest pain [ ] Palpitation [ ] Dyspnea [ ] Dizziness [ ] Wheezing [ ] Facial/lip swelling [ ] Hives/urticaria [ ] Pruritus Other:________________________________
Medications used BEFORE event (and time if available)		[ ] Heparin __:__ [ ] Hectorol (Cholecalciferol) __:__ [ ] EPO__:__ [ ] Saline__:__ [ ] Iron __:__ Other:_______________________________________________
Resuscitation effort		Was CPR done: Yes/No Where_________By whom:___________ Time started:__:__ Any data on cardiac rhythm:_______________ Blood glucose:____ Other notable lab (K+, Ca++…) before event:________________ Intubation done: Yes/No If yes, is airway edema noted: Yes/No
Outcome		[ ] Survived, continue dialysis session [ ] Survived, admitted to hospital [ ] Died
Other notes:
Medical examiner notes (if any):

Public reporting burden of this collection of information is estimated to average 30 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. 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. Send comments regarding this burden estimate or any other aspect of this collection of information including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74 Atlanta, Georgia 30333; ATTN: PRA (0920-XXXX)