Inventory of ICs Y2Q1

Case ID#: _______________________

Form Approved;
1
OMB No. 0920-1011;
Exp Date: 3/31/2017

☐ NOT A CASE
ADVERSE HEALTH EFFECTS ASSOCIATED WITH
SYNTHETIC CANNABINOID USE — MISSISSIPPI, 2015
MEDICAL RECORDS REVIEW

Reviewer: ______________________Agency:________________Abstraction Date :(mm/dd/yyyy):__________

PATIENT IDENTIFICATION
Hospital Name

Full Name (Last Name, First Name)

Sex
☐M
☐F
Age

Date of Birth (mm/dd/yyyy)

Phone/Home: ________________________
Phone/Cell:__________________________
If not recorded, please enter 000-000-0000
Address

Medical Record Number
Race (check all that apply):
☐Amer Ind/AK native ☐Asian ☐ Black/Afr Am
☐Native HI/other PI
☐White
☐Other (specify)___________________________
☐ Not documented
Poison Control Center Number
☐ None
County

City/State/Zip

SPECIMENS
Specimen(s) available? (earliest available specimen(s) preferred) ☐ Yes ☐ No ☐ Unknown
1st Specimen
Type of specimen: ☐ Whole blood ☐ Serum ☐ Urine ☐ Drug Sample/Specimen
If yes, specify:

☐ Sent to outside lab

If sent, name of lab: _____________ State Specimen ID: ________

Results Available : ☐ Yes ☐ Pending ☐ Unknown
If available, ☐ Synthetic Cannabinoid (name): ______________________________
☐ Illicit drugs (name): ___________________________________________
☐ Other (name): ________________________________________________
2nd Specimen
Type of specimen: ☐ Whole blood
If yes, specify:

☐ Serum

☐ Sent to outside lab

☐ Urine

☐ Drug Sample/Specimen

If sent, name of lab: _____________ State Specimen ID: ________

Results Available : ☐ Yes ☐ Pending ☐ Unknown
If available, ☐ Synthetic Cannabinoid (name): ______________________________
☐ Illicit drugs (name): ___________________________________________
☐ Other (name): ________________________________________________
2nd Specimen
Type of specimen: ☐ Whole blood
If yes, specify:

☐ Serum

☐ Sent to outside lab

☐ Urine

☐ Drug Sample/Specimen

If sent, name of lab: _____________ State Specimen ID: ________

Results Available : ☐ Yes ☐ Pending ☐ Unknown
If available, ☐ Synthetic Cannabinoid (name): ______________________________
☐ Illicit drugs (name): ___________________________________________
☐ Other (name): ________________________________________________
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 (0920-1011)

Case ID#: _______________________
2

MEDICAL RECORDS ABSTRACTION
Type of Records reviewed (mark all that apply):
☐ Coroner/Medical Examiner Documentation***
☐ Emergency Medical Services (EMS)/Ambulance
notes*
☐ Poison Center Chart
☐ Emergency Department Notes
☐ Other _____________________
☐ Hospital chart**
*If patient not brought in or seen by EMS, complete disposition and skip to Section B.
**If patient was admitted also complete Section C
***If patient is deceased also complete Section D.
Mode of Presentation to ED:
☐ Self/Ambulatory ☐ Friends/Family ☐ Ambulance ☐ Police ☐ Transfer
☐ Other ______________

Presentation & Disposition
Date of presentation (mm/dd/yyyy): _______________

☐ Not Recorded

Disposition (Check all that apply)

☐ Not recorded

☐ Left AMA (Against Medical Advice)
☐ Treated and Released
☐ Admitted to observation (OBS)
☐ Admitted to General Medicine
☐ Admitted to ICU
☐ Deceased

Date: ________________ (mm/dd/yyyy)
ED discharge date: ________________ (mm/dd/yyyy)
OBS discharge date: __________________(mm/dd/yyyy)
Hospital discharge date: __________________(mm/dd/yyyy)
ICU discharge date: _________________ (mm/dd/yyyy)
Date of death: __________________(mm/dd/yyyy)

Discharge Diagnosis: (select all that apply)

☐ Not recorded

☐ Drug Overdose

☐ Altered Mental Status

☐ Seizure

☐ Tachycardia

☐ Hyperthermia

☐ Hypertension

☐ Acute Renal Failure

☐ Rhabdomyolysis

☐ Respiratory Failure

☐ Cardiopulmonary Arrest

☐ Other: _____________________________

General Information
Chief Complaint (first recorded by MD or other practitioner):

Synthetic cannabinoid use:
☐ Not recorded ☐ Yes
Synthetic cannabinoid use details (product name, quantity, place obtained, etc.)
Name of synthetic cannabinoid product:_________________________________ ☐ Not recorded
Time passed since last use: ☐ ≤ 24 hours ☐ >24-36 hours ☐ >36 hours
☐ Not recorded
Other details:
Mental Status prior to Medication Administration
(mark all that apply, including those in chief
complaint):

Obtained from:
☐ Prehospital Records
☐ Transfer Records
☐ Medical Examiner / Coroner

☐ ED Records
☐ Hospital Records

Case ID#: _______________________
3
☐ Normal ☐ Not recorded
☐ Agitated ☐ Confused ☐ Violent/Aggressive ☐ Hallucinating ☐ Paranoid
☐ Anxious ☐ Somnolent ☐ Unresponsive
☐ Seizures
☐ Psychosis
☐ Other_____________________
Past Medical History
☐ No Past Medical History

☐ Yes (if yes, specify below)

☐ Not recorded

☐ High blood pressure
☐ Heart disease
☐ Kidney disease
☐ Liver disease
☐ Diabetes
☐ Seizure disorder
☐ Mental illness
☐ Substance abuse
☐ Other ________________________
Review of Symptoms at Time of Presentation
(mark all that apply):
☐ Not recorded
☐ Fatigue
☐ Chest Pain
☐ Nausea/Vomiting
☐ Palpitations
☐ Headache
☐ Shortness of Breath
Other: _____________________

☐ Abdominal Pain
☐ Dark Urine
☐ Muscle pain

☐ Sweating
☐ Confusion

Physical Exam Findings/Descriptors at Time of Presentation
(mark all that apply):
Skin:
☐ Normal ☐ Not recorded
☐ Diaphoretic (sweating)
☐ Flushed
☐ Other_______________
Mucous Membranes: ☐ Normal ☐ Not recorded
☐ Dry
☐ Other______________
Eyes:
☐ Normal ☐ Not recorded
☐ Pupils dilated ☐ Pupils constricted ☐ Nystagmus ☐ Injected Eyes ☐ Other________
Cardiovascular:
☐ Normal ☐ Not recorded
☐ Tachycardia ☐ Bradycardia ☐ Arrhythmia
☐ Other_________
Respiratory:
☐ Normal ☐ Not recorded
☐ Bradypnea ☐ Tachypnea ☐ Dyspnea ☐ Other_________
Gastrointestinal:
☐ Normal ☐ Not recorded ☐ Vomiting
☐ Abnormal bowel sounds ☐ Tender ☐ Other_________
Neurologic:
☐ Normal ☐ Not recorded ☐ Altered Mental Status
☐ Hyperreflexia
☐ Hyporeflexia
☐ Tremor
☐ Other _________

Case ID#: _______________________
4
☐ Normal ☐ Not recorded
☐ Rigidity ☐ Weakness
☐ Other _______
If exam findings present, specify where (e.g., extremities, generalized)__________________

Musculoskeletal:

Initial Basic Laboratory Evaluation:
Blood Chemistry:

☐ Not Recorded ☐ Performed

Na
☐ Normal
K
☐ Normal
Cl
☐ Normal
HCO3
☐ Normal
BUN
☐ Normal
Creatinine ☐ Normal
Glucose ☐ Normal
Anion Gap ☐ Normal

☐ Abn Value: ________
☐ Abn Value: ________
☐ Abn Value: ________
☐ Abn Value: ________
☐ Abn Value: ________
☐ Abn Value: ________
☐ Abn Value: ________
☐ Abn Value: ________

Blood gas: ☐ Not Recorded
pH
PaO2
PaCO2
HCO3

Liver Panel: ☐ Not Recorded
Total protein
Albumin
AST
ALT
Total Bili
Alk Phos
Other:
CK/CPK
Lactate
Troponin

☐ Performed
☐ Normal ☐ Abn Value:
☐ Normal ☐ Abn Value:
☐ Normal ☐ Abn Value:
☐ Normal ☐ Abn Value:
☐ Normal ☐ Abn Value:
☐ Normal ☐ Abn Value:

________
________
________
________
________
________

☐ Not Recorded ☐ Normal ☐ Abn Value: _______
☐ Not Recorded ☐ Normal ☐ Abn Value: _______
☐ Not Recorded ☐ Normal ☐ Abn Value: _______

☐ Performed

☐ Normal ☐ Abn Value: ________
☐ Normal ☐ Abn Value: ________
☐ Normal ☐ Abn Value: ________
☐ Normal ☐ Abn Value: ________

☐ Supplemental O2 If yes, Specify: _____FiO2
Urine Drug Screen ☐ Not recorded ☐ Performed
If performed, mark all that apply
Benzodiazepines (BZD)
Amphetamine
Cocaine (benzylecgonine)
Cannabinoids (THC)
Opioids
Barbiturates
Other(s)___________

☐ Positive
☐ Positive
☐ Positive
☐ Positive
☐ Positive
☐ Positive
☐ Positive

☐ Negative
☐ Negative
☐ Negative
☐ Negative
☐ Negative
☐ Negative
☐ Negative

Blood Drug Screen: ☐ Not recorded
If performed, mark all that apply

☐ Performed

☐ Ethanol
☐ Positive ☐ Negative
☐ Other(s)_________________________ ☐ Positive ☐ Negative

Electrocardiographic (ECG/EKG) or Telemetry Findings (e.g. rhythm strip) Physician Interpretation at Presentation:

Case ID#: _______________________
5
Initial cardiac rhythm: ☐ Not recorded ☐ Normal sinus
☐ Abnormal, please describe:_____________________________________

Imaging Findings at Presentation
☐ Not Recorded ☐ Performed
If performed, mark all that apply:
☐ Head CT

☐ Normal ☐ Abnormal

☐ Chest X-ray

☐ Normal ☐ Abnormal Specific abnormal findings________________________________

☐ Other(s) Specify___________

A.

Specific abnormal findings_______________________________

☐ Normal ☐ Abnormal Specific abnormal findings___________________

Prehospital Data
Earliest Prehospital Vital Signs ☐ Cardio Pulmonary Arrest

☐ No Prehospital Data Available

☐ Not Recorded

Date:__________(mm/dd/yyyy)
Temperature ______°☐F ☐C (Temp: ☐ Not Recorded)
Respiratory Rate:______/minute

Heart Rate:______/minute;

Blood Pressure:_____/_____

%O2 Saturation: ______% (O2 sat: ☐ Not Recorded)

Prehospital Interventions
☐ Not Recorded ☐ Performed
If performed, mark all that apply:
☐ Intubation, specify reason (e.g. hypoventilation, airway protection) ______________________
☐ Cardiopulmonary resuscitation
☐ Defibrillation
Prehospital Medications
☐ Not Recorded ☐ Performed
If performed, mark all that apply:
☐ Benzodiazepine
Name (s) :_________________________________
☐ Antipsychotics
Name (s):_________________________________
☐ Antidotes
Name (s):_________________________________

B. ED Data
Earliest ED Vital Signs: ☐ Cardio Pulmonary Arrest

☐ No ED Data Available

☐ Not Recorded

Date:__________(mm/dd/yyyy)
Temperature ______°☐F ☐C

Heart Rate:______/minute;

Respiratory Rate:______/minute

% Oxygen Saturation: _____ %

Blood Pressure:_____/_____

Case ID#: _______________________
6
ED Interventions
☐ Not Recorded ☐ Performed
If performed, mark all that apply:
☐ Intubation, specify reason (e.g. hypoventilation, airway protection) ______________________
☐ Cardiopulmonary resuscitation
☐ Defibrillation
☐ Hemodialysis
☐ Cooling Measures
ED Medications (see instruction sheet for included medications)
☐ Not Recorded ☐ Performed
If performed, mark all that apply:
☐ Benzodiazepine
Name (s) :_________________________________
☐ Antipsychotics
Name (s):_________________________________
☐ Antidotes
Name (s):_________________________________
☐ Vasopressor
Name (s): _________________________________

C. Inpatient Data

☐ No Inpatient Data Available

Most abnormal laboratory values during hospitalization
Blood Chemistry: ☐ Not Recorded ☐ Performed
If abnormal, specify max values during hospitalization

Na
K
HCO3
BUN
Creatinine
Glucose
Anion Gap

☐ Normal
☐ Normal
☐ Normal
☐ Normal
☐ Normal
☐ Normal
☐ Normal

Lowest
Highest
Abnormal Abnormal
Value
Value
_______ _______
_______ _______
_______ _______
_______
_______
_______ _______
_______

Liver Panel: ☐ Not Recorded ☐ Performed
If abnormal, specify max values during hospitalization

AST
ALT
Total Bili
Alk Phos
Other:
CK/CPK
Lactate/Lactic Acid
Troponin

☐ Not Recorded
☐ Not Recorded
☐ Not Recorded

Highest
Abnormal
Value

☐ Normal
☐ Normal
☐ Normal
☐ Normal

_______
_______
_______
_______

☐ Normal
☐ Normal
☐ Normal

_______
_______
_______

Inpatient Interventions
☐ Not Recorded ☐ Performed
If performed, mark all that apply:
☐ Intubation, specify reason (e.g. hypoventilation, airway protection) ______________________
☐ Cardiopulmonary resuscitation
☐ Defibrillation
☐ Hemodialysis
☐ Cooling Measures
Inpatient Medications
☐ Not Recorded ☐ Performed
If performed, mark all that apply:
☐ Benzodiazepine
Name (s) :_________________________________
☐ Antipsychotics
Name (s):_________________________________
☐ Antidotes
Name (s):_________________________________
☐ Vasopressor
Name (s): _________________________________

Case ID#: _______________________
7
Other Data/Notes:

D. ME or Coroner Record Review

☐ No Prehospital Data Available

Date and Time of Death (mm/dd/yyyy)/(hh:mm A.M./P.M.):
☐ Check if time of death is estimated
Significant Positive Gross Autopsy Findings:

Significant Positive Histopathology Autopsy Findings:

Blood Chemistry: ☐ Not Recorded ☐ Performed
If abnormal, specify max values during hospitalization

Na
K
HCO3
BUN
Creatinine
Glucose
Anion Gap

☐ Normal
☐ Normal
☐ Normal
☐ Normal
☐ Normal
☐ Normal
☐ Normal

Lowest
Highest
Abnormal Abnormal
Value
Value
_______ _______
_______ _______
_______ _______
_______
_______
_______ _______
_______

Liver Panel: ☐ Not Recorded ☐ Performed
Highest
If abnormal, specify max values during hospitalization

AST
ALT
Total Bili
Alk Phos
Other:
CK/CPK
Lactate/Lactic Acid
Troponin

☐ Not Recorded
☐ Not Recorded
☐ Not Recorded

Highest
Abnormal
Value

☐ Normal
☐ Normal
☐ Normal
☐ Normal

_______
_______
_______
_______

☐ Normal
☐ Normal
☐ Normal

_______
_______
_______

Case ID#: _______________________
8
Drug Screen:
☐ Not Recorded ☐ Performed
If performed, mark all that apply
Ethanol
☐ Negative
Opioids
☐ Negative
Benzodiazepines ☐ Negative
Cocaine
☐ Negative
Barbiturates
☐ Negative
Methamphetamines☐ Negative
THC/cannabinoids ☐ Negative

☐ Blood +
☐ Blood +
☐ Blood +
☐ Blood +
☐ Blood +
☐ Blood +
☐ Blood +

☐ Urine +
☐ Urine +
☐ Urine +
☐ Urine +
☐ Urine +
☐ Urine +
☐ Urine +

Other Drug Screen:
☐ Not Recorded ☐ Performed
If performed, mark all that apply
☐ Other: ________ ☐ Negative
☐ Other: ________ ☐ Negative
☐ Other: ________ ☐ Negative
☐ Other: ________ ☐ Negative
Synthetic cannabinoid use:
☐ Not recorded ☐ Yes

☐ Blood +
☐ Blood +
☐ Blood +
☐ Blood +

☐ Urine +
☐ Urine +
☐ Urine +
☐ Urine +

Synthetic cannabinoid use details (product name, quantity,
place obtained, etc.)
Name of synthetic cannabinoid:______________________
Other details:
Other Data/Notes (please include any past medical history or any pertinent case history listed):

Cause of Death: ____________________________________________________________________
SPECIFIC MENTAL STATUS DESCRIPTORS:
Normal
AAOx3
Alert and Oriented
Agitated-Delirium
AGITATION or EXCITATION PLUS one of following:
Delirious
Delirium
Confused
Altered / Altered mental status
Violent
Violent
Angry
Agitated (but not delirious)
Hallucinating
Visual hallucinations
Auditory hallucinations
Paranoid
Paranoid / Paranoia
Anxious
Anxious
Nervous
Somnolent
Somnolent

Fatigued
Sedated
Sleeping
Depressed mental status
Difficult to arouse
Unresponsive
Unresponsive
Comatose / Coma
GCS-3
Seizures
Seizures
Seizure-like activity
Epileptic activity
Psychosis/Psychotic
Psychosis
Psychotic
Out of touch with reality
SPECIFIC MEDICATION DESCRIPTORS:
Do not include medications used in CPR/ACLS/code
Benzodiazepines:
Lorazepam (Ativan)
Diazepam (Valium)
Midazolam (Versed)
Alprazolam (Xanax)
Clonazepam (Klonopin)

Case ID#: _______________________
9
Antipsychotics:
Haldoperidol (Haldol)
Chlorpromazine (Thorazine)
Droperidol (Inapsine)
Prochlorperazine (Compazine)
Aripiprazole (Abilify)
Olanzapine (Zyprexa)
Quetiapine (Seroquel)
Ziprazidone (Geodon)
Risperidone (Risperdol)

Intralipid

Antidotes:
Naloxone (Narcan)
Flumazenil (Romazicon)
Physostigmine (Antilirium)
N-acetyl cysteine (Acetadote)
Activated charcoal
Calcium
Dantrolene
Bromocriptine
High-dose insulin

SPECIFIC COOLING MEASUES:
Active cooling
Fans / Fans Cooling
Removing all clothing
Ice bath
Ice pack

Vasopressors:
Epinephrine (Adrenalin)
Norepinephrine (Levophed)
Vasopressin (Vasostrict)
Dopamine (Intropin)
Dobutamine
Milrinone

Form Approved;
OMB No. 0920-1011;
Exp Date: 03/31/2017

ADVERSE HEALTH EFFECTS ASSOCIATED
WITH
SYNTHETIC CANNABINOID USE —
MISSISSIPPI, 2015
PATIENT (OR
SURROGATE)
INTERVIEW
Interviewer: ________________________ Agency:
_____________ Date:(mm/dd/yyyy):____/____/_______

NARRATIVE #1 – For Adults
My name is (YOUR NAME) and I’m from the
Mississippi health department. We have
recently seen an increase in people getting
sick from synthetic marijuana. We want to
learn why you and other people are getting
sick, and how we can help prevent others
from getting sick. You are free to choose if
you want to participate in this survey. Also,
you are free to skip any questions you do not
wish to answer, and you may decide to end
the interview at any time. Everything you say
is confidential. Your name is not attached to
any of your answers, and we do not report
any of your information to the authorities.
Would you be willing to take a few minutes to
talk with us? (If asked will take approximately
15-20 minutes to complete.)
☐ Yes ☐ No; If “Yes,” start questionnaire
with Question 1.
If “No,” then read the Closing Statement on
the last page.

NARRATIVE #2 – For Minors
My name is (YOUR NAME) and I’m from the
Mississippi health department. We have
recently seen an increase in people getting
sick from synthetic marijuana. We want to
learn why (PATIENT’S NAME) and other
people are getting sick, and how we can help

prevent others from getting sick. We would
like your permission to ask (PATIENT’S
NAME) a few questions about this hospital
visit. (PATIENT’S NAME) is free to choose if
they want to participate in this survey. Also,
(HE/SHE) is free to skip any questions they
do not wish to answer, and (HE/SHE) may
decide to end the interview at any time.
Everything (HE/SHE) says is confidential.
(HIS/HER) name is not attached to any of
the answers, and we do not report any of
their information to the authorities. Would
you be willing to take a few minutes to talk
with us? (If asked will take approximately 1520 minutes to complete.)
☐ Yes ☐ No; If “Yes,” start questionnaire
with Question 1.
If “No,” then read the Closing Statement on
the last page.
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 (0920-1011)

SYNTHETIC MARIJUANA USE (GENERAL)
Now I am going to ask you questions about
synthetic marijuana or Spice and other
recreational drugs you may have used.

1. Were you aware that over the past month many
people in Mississippi have been getting sick after
using synthetic marijuana?
☐ Yes
☐ No
☐ Don’t know
☐ Refused
1a. If yes: how did you find out? (Read options and
check all that apply)
☐ TV/Radio,
specify____________________________________
___________________________________
☐ Social media (e.g. Facebook, Twitter, Instagram),
specify____________________________________
___
☐ Internet website,
(specify)___________________________________
______________________________
☐ Friend
☐ Family member
☐ Other,
(specify)___________________________________
_______________________________________
2. Why do you choose to use synthetic marijuana?
__________________________________________
____
3. How long have you been using synthetic
marijuana?
☐ First time ☐ Less than 1 year ☐ More than 1
year ☐ Don’t Know ☐ Refused
4. How often did you use synthetic marijuana in the
past 30 days?
☐ One time only (this episode) ☐ Less than once a
week ☐ Once a week ☐ Several times a week
☐ Daily
☐ Don’t know
☐ Refused

DETAILS OF SYNTHETIC MARIJUANA USE
Now I am going to ask some questions related to
the synthetic marijuana product you used
in the past 24 hours.

5. What was the brand/street name of the synthetic
marijuana product that you used in the past 24
hours? ☐ Spice ☐ K2
☐ Crazy Monkey
☐ Black Mamba
☐ Mojo
☐ Skunk
☐ Moon Rocks
☐ Yucatan Fire
☐ AK-47
☐ Other
__________________________
☐ Don’t Know
☐ Refused
6. Do you remember what the packaging looked
like?:
☐ Yes,
specify________________________________________
____________________________________
☐ No
☐ Don’t Know ☐ Refused
7. Have you ever used
before? ☐ Yes
☐ No
☐ Don’t Know
☐
Refused
If No/Don’t Know/Refused, skip to question 11
7a. If yes: how many times have you ever used
? ☐ Once ☐ 25 times ☐ > 5 times
☐ Don’t Know ☐
Refused
8. Other than this time, have you ever gotten
sick after using ?
☐ Yes
☐ No
☐ Don’t Know ☐
Refused
9. Did you notice anything different about this
(such as the
appearance,
taste, or smell) compared to other times
you’ve used ? ☐ Yes
☐ No
☐ Don’t Know ☐ Refused
9a. If yes: What did you notice was
different?:________________________________
________________
10. Did you notice anything different about how
this made you feel
compared to other times you’ve used ? ☐ Yes
☐ No
☐ Don’t
Know
☐ Refused
10a. If yes: What did you notice was
different?:_________________________________
_____________

11. Why do you think you got sick this time?
__________________________________________
____________
12. How did you use this product in the past 24
hours? (Read options and check all that apply)
☐ Smoke
☐ Vaping ☐ Eat or Swallow ☐
Snort
☐ Intravenous ☐
Other_________________
☐ Don’t Know ☐ Refused

17. What should we tell people about synthetic
marijuana?
__________________________________________
__________________________________________
__

_____________________________________________
__________________________________________
18. What’s the best way to get the word out?

13. Was this different than the way you usually use
it?
☐ Yes
☐ No
☐ Don’t have normal method
☐ Don’t Know ☐ Refused
14. Without giving a specific name, where did you
get this product? (Read options and check all that
apply)
☐ Convenience store/Gas station
☐
Tobacco store/Head shop
☐ Bought from a dealer
☐
From a friend or family member
☐ Internet
☐
Party or Rave
☐ Other,
specify____________________________________
_____________________________________
☐ Don’t know ☐ Refused
15. Do you know if anyone else who used the same
product as you got sick?
☐ Yes
☐ No
☐ Don’t Know
☐ Refused
15a. If yes: Did they have to go to the hospital
because of it? ☐ Yes ☐ No ☐ Don’t Know ☐
Refused
16. In the past 24 hours, did you also use any street
drugs or prescription drugs recreationally?
☐ Yes,
specify_________________________________
_______________________________________
____
☐ No
☐ Don’t Know ☐Refused
Regarding Question 16 – Data entry team will
categorize the drug name:
☐ Alcohol ☐ Tobacco ☐ Regular Marijuana ☐
Heroin or Opioids ☐ Cocaine ☐Methamphetamines
☐ Bath Salts ☐ Benzodiazepines ☐ Other, specify:
__________________________________________
_

CLOSING QUESTIONS/COMMENT

_____________________________________________
_________________________________________

19. Notes or comments:
__________________________________________
__________________________

_____________________________________________
_________________________________________

Closing Statement:
Thank you for your time. For your information,
there have been reports of people getting sick
after using synthetic marijuana in Mississippi. If
you would like more information about
synthetic marijuana, please contact Mississippi
Poison Control Center at 1-800-222-1222, or go
to the website http://msdh.ms.gov/msdhsite/_static/23,16273,1
95.html