Form DAWN Case Report F DAWN Case Report F DAWN Case Report Form

OMB No. 0930-0078 Expires XX/XX/XXXX

Emergency Department Case Report
Drug and Alcohol Warning Network

U.S. Department of Health and Human Services  •  Substance Abuse and Mental Health Services Administration  •  Center for Behavioral Health Statistics and Quality

Hospital Emergency Department ID  XXXXX
1. Date of Visit

2. Time of Visit

MONTH DAY

YEAR

20

HOUR

3. Age
MINUTE

☐ 4 weeks (28 days) or younger
☐ Between 4 weeks and one
year old (>4 weeks, <1 year)
☐ Not documented

☐ a.m.
☐ p.m.
☐ military

4. Patient’s County of Residence

Enter the patient’s ZIP Code to identify their county of residence. (ZIP Code will not be saved).
Select one if living situation applies or county of residence cannot be determined.
☐ No fixed address (e.g., homeless)
☐ Outside U.S.
☐ Institution (e.g., shelter/jail/hospital)
☐ Unable to determine county
5. Sex
☐ Male
☐ Female
☐ Not documented

6. Gender Identity

7. Sexual Orientation

8. Ethnicity (select one)
☐ Hispanic or Latino
☐ Not Hispanic or Latino
☐ Not documented
☐ Not available

9. Race (check all that apply)
☐ White
☐ Black or African American
☐ Asian
☐ American Indian or Alaska Native

[free text]

[free text]

☐ Facility does not collect gender identity
☐ Facility collects gender identity,
but it is not documented

☐ Facility does not collect sexual orientation
☐ Facility collects sexual orientation,
but it is not documented

Native Hawaiian or Other Pacific Islander
Other
Not documented
Not available

☐
☐
☐
☐

10. Case Description Beginning with the presenting complaint, describe how the substance(s) was related to the ED visit. Copy verbatim from the
patient’s record when possible. Do not include information that could identify the patient or hospital.

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12. Diagnosis List all diagnoses in the patient’s record. (Do not list ICD codes.)

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Route of Administration
Select One

al

11. Substance(s) Involved Using available documentation, list all substances
that caused or contributed to the ED visit. Record substances as specifically
as possible (i.e., brand (trade) name preferred over generic name preferred
over chemical name, etc.). Do not record the same substance by two
different names. Do not record current medications unrelated to the visit.

13. Type of Case Select the first category that applies.
☐Suicide

attempt
☐Seeking

detox and/or substance abuse treatment only
☐Alcohol

only
☐Adverse

reaction
☐Overmedication

☐Malicious

poisoning
☐Accidental

ingestion
☐Other

14. Was naloxone administered to the patient in the ED?
☐ Yes
☐ No
☐ Not documented

15. Was
 
buprenorphine administered
to the patient in the ED?
☐ Yes
☐ No
☐ Not documented

16. Was
 
methadone administered to
the patient in the ED?
☐ Yes
☐ No
☐ Not documented

If yes, was buprenorphine administered
to the patient for: (Select all that apply.)
☐ To alleviate opioid withdrawal symptoms
☐ Treatment of pain
☐ To initiate medication assisted
treatment (MAT)
☐ Not documented

If yes, was methadone administered to
the patient for: (Select all that apply.)
☐ To alleviate opioid withdrawal symptoms
☐ Treatment of pain
☐ To initiate medication assisted treatment (MAT)
☐ Not documented

17. Disposition–Select one:
ED Departure
☐ Home
☐ Return/transfer to jail/prison/
law enforcement
☐ Referred to substance
abuse treatment
☐ Referred to psychiatric/
counseling treatment
☐ Referred to substance abuse
treatment AND psychiatric/
counseling treatment

Transferred
☐ Substance abuse
treatment facility
☐ Psychiatric/counseling facility
☐ Combined svubstance abuse
treatment and psychiatric/
counseling treatment facility
☐ Other facility

Admitted
☐ ICU/critical care
☐ Substance abuse treatment unit
☐ Psychiatric unit
☐ Combined substance abuse
treatment/psychiatric unit
☐ Other inpatient unit

Other
☐ Left against medical advice
☐ Died
☐ Other
☐ Not documented

18. Comments Enter any questions or issues you have about this case. Do not include information that could identify the patient or hospital.

Public Burden Statement: 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. The OMB control number for this project is 0930-0078. Public reporting burden for this collection of
information is estimated to average 81.5 hours per year, including the time for reviewing instructions, searching existing data sources, gathering, and
maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other
aspect of this collection of information, including suggestions for reducing this burden, to SAMHSA Reports Clearance Officer, 5600 Fishers Lane,
Room 15E45,Rockville, Maryland, 20857.