Pre-Hospital Care Data - PCNASP Awardee - hospital respondents

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