Attachment 4a_Pre hospital data elements_Clean

Paul Coverdell National Acute Stroke Program (PCNASP) Reporting System

Attachment 4a_Pre hospital data elements_Clean

OMB: 0920-1108

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DRAFT Form Approved

OMB No. 0920-1108

Exp. Date 09/30/2022


Instructions for Paul Coverdell National Acute Stroke Program (PCNASP) Pre-Hospital Data Elements


Public reporting of this collection of information is estimated to average 30 minutes/hours per response, including the time for reviewing instructions 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 current 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 (0920-1108).

Scene Arrival

<ScnArrD>


_ _/ _ _/ _ _ _ _

Date MMDDYYYY

 

Required

<ScnArrT>


___: ____

Time HHMM

 

Required

Scene Departure

<ScnDptD>


_ _/ _ _/ _ _ _ _

Date MMDDYYYY

 

Required

<ScnDptT>


___: ____

Time HHMM

 

Required

Patient Age

<Age>

Age |__|__|__| years

Numeric ### = 3-digit

0 < age < 125

 Prepopulated from in-hospital data

Required

Patient Gender

<Gender>

Gender

Numeric # = 1-digit

1 - Male; 2 - Female; 3 - Unknown

Select only 1 gender

Prepopulated from in-hospital data

Required

Pre-hospital stroke screen performed

<StkScn>

Did EMS perform a pre-hospital stroke screen?

Numeric # = 1-digit

1 - Yes; 2– No; 3 – Not documented

 

Required

<EMSGlu>

Glucose level

Numeric # = 3-digit


*GWTG: mg/dL; for glucometers that don’t produce a numeric value enter 600 for high and 20 for low

Required



File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
AuthorOdom, Erika C. (CDC/ONDIEH/NCCDPHP)
File Modified0000-00-00
File Created2022-02-04

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