OMB Control Number: 2127-NEW
Expiration Date: XX/XX/XXXX
Prevalence of Alcohol and Other Drug Use among Motor Vehicle Crash Victims Admitted to Select Trauma Centers
De-identified Data Provided by Trauma Center or Medical Examiner
(All data are from secondary sources)
Mechanism of Injury
Case Start Location
Trauma Center
Medical Examiner
Mechanism of Injury
Motor vehicle crash
Other motorized transportation
Non-motorized transportation
Fall
Drowning
Fire/burn
Nature/environmental
Other trauma, unspecified
Other trauma, specified
Position in Crash
Driver (including motorcycle)
Passenger (including motorcycle)
Bicycle rider/ driver
Pedestrian
Scooter
Unknown vehicle occupant location
Other: ________
Not applicable
Type of motor vehicle
Car
SUV
Pick-up truck
Van
Motorcycle
Semi-truck
Other commercial vehicle: ________
Other passenger vehicle: ________
Cannot be determined
Not applicable
Protective Devices (select all that apply)
Airbag
Seatbelt
Helmet
Unknown
None
Not applicable
Drug Administered Prior to Arrival (select all that apply)
None
Ativan
Fentanyl
Morphine
Versed
Arrival Day/Time
Arrival Day of Week
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Arrival Month
January
February
March
April
May
June
July
August
September
October
November
December
Arrival Time
12:00am-2:59am
3:00am-5:59am
6:00am-8:59am
9:00am-11:59am
12:00pm-2:59pm
3:00pm-5:59pm
6:00pm-8:59pm
9:00pm-11:59pm
Blood Tube Scan
Blood Tube ID: ________
Demographics
Age (in years)
18-20
21-34
35-64
65+
Sex
Male
Female
Race (select all that apply)
White
Black or African American
Asian
Native American or Alaska Native
Hawaiian or Pacific Islander
More than one race
Unknown
Other: ________
Hispanic/Latino
Yes
No
Treatment and Outcomes
Trauma Designation
Alert
1
2
3
Drugs Administered Prior to blood draw (select all that apply)
None
Ativan
Dilaudid
Etomidate
Fentanyl
Haldol
Morphine
Versed
TRISS: ________
ISS: ________
ICD-10 Code: ________
Deceased
Yes
No
Death Day of Week
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Death Month
January
February
March
April
May
June
July
August
September
October
November
December
Time of Death
12:00am-2:59am
3:00am-5:59am
6:00am-8:59am
9:00am-11:59am
12:00pm-2:59pm
3:00pm-5:59pm
6:00pm-8:59pm
9:00pm-11:59pm
Drugs for screening and confirmation with cutoff levels
Drugs: Grouped by Class/Screening Package |
Minimum Blood Concentration Detection Thresholds (ng/mL) |
|
|
ELISA Screen |
LC-MS/MS Confirm |
Cocaine, benzoylecgonine, cocaethylene |
25 |
10 |
6-AM, codeine, morphine, hydrocodone, hydromorphone |
25 |
10 |
Amphetamine, methamphetamine, MDMA, MDA, ephedrine, pseudoephedrine, phenylpropanolamine |
20
|
10 |
THC, THC-COOH, 11-OH-THC |
5 |
1 |
Phencyclidine |
10 |
10 |
Buprenorphine, norbuprenorphine |
1 |
1 |
Alprazolam, chlordiazepoxide, oxazepam, nordiazepam, lorazepam, diazepam, clonazepam, 7-aminoclonazepam, temazepam |
20 |
10 |
Phenobarbital, secobarbital, butalbital |
100 |
100 |
Methadone, EDDP |
50 |
10 |
Diphenhydramine, doxylamine, chlorpheniramine |
25 |
10 |
Fentanyl, norfentanyl, furylfentanyl, acetylfentanyl, carfentanil, fluorofentanyl |
1 |
0.5 |
Oxycodone; Oxymorphone |
25 |
10 |
Tramadol |
50 |
10 |
Carisoprodol; Meprobamate |
500 |
500 |
Sertraline |
50 |
10 |
Fluoxetine |
50 |
10 |
Amitryptiline, nortriptyline, doxepin, imipramine, desipramine, citalopram, venlafaxine, trazadone, cyclobenzaprine |
25 |
10 |
Zolpidem |
10 |
10 |
Dextromethorphan |
50 |
20 |
Ketamine |
10 |
10 |
α-Pyrrolidinopentiophenone |
5 |
1 |
NHTSA Form 1421
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Lindsey Graham |
| File Modified | 0000-00-00 |
| File Created | 2021-01-15 |