**Natural Disaster Morbidity Report Form**

For Active Surveillance in Shelters with Medical Staff

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<td><p><u>Part I:</u></p>
<p><u>Visit</u></p>
<p><u>Information</u></p></td>
<td colspan="2"><p>Location &amp; Name of Facility</p></td>
<td>2-Letter State</td>
<td colspan="2">Date of Visit</td>
<td colspan="4">Time of Visit</td>
<td colspan="2">Encounter: (circle one)</td>
</tr>
<tr class="even">
<td><p><u>Part II:</u></p>
<p><u>Patient Information</u></p></td>
<td colspan="3">Unique Identifier / Medical Record Number</td>
<td>Age</td>
<td colspan="4">Sex</td>
<td colspan="2"><p>Pregnant</p>
<p> Yes</p></td>
<td>If pregnant, due date</td>
</tr>
<tr class="odd">
<td colspan="12">Race / Ethnicity White Black/African American Hispanic
or Latino Asian Unknown</td>
</tr>
<tr class="even">
<td colspan="12"><u>Part III: REASON FOR VISIT (Please check all
categories related to patient’s current reason for seeking
care.)</u></td>
</tr>
<tr class="odd">
<td colspan="2" rowspan="5"><p> <strong>INJURY</strong></p>
<p> Bite/Sting</p>
<p> Animal</p>
<p> Insect</p>
<p> Snake</p>
<p> Burn</p>
<p> Chemical</p>
<p> Fire, hot object or substance</p>
<p> Sun exposure</p>
<p> Cold-related (e.g., hypothermia)</p>
<p> Cut</p>
<p> Debris</p>
<p> Machinery (e.g., chainsaw)</p>
<p> Drowning/Submersion</p>
<p> Electrocution</p>
<p> Fall <strong>specify:</strong></p>
<p> From height</p>
<p> Same level</p>
<p> Foreign Body (e.g. in eye, splinter)</p>
<p> Heat-related</p>
<p> Hit by object</p>
<p> Poisoning <strong>specify:</strong></p>
<p> CO exposure</p>
<p> Inhalation of fumes, dust, or gas</p>
<p> Ingestion</p>
<p> Vehicle collision <strong>specify:</strong></p>
<p> Driver/occupant</p>
<p> Pedestrian</p>
<p> Violence / assault <strong>specify:</strong></p>
<p> Sexual assault</p>
<p> Suicide / self-inflicted injury</p>
<p> Other assault</p>
<p> Undetermined, nonspecific</p></td>
<td colspan="5" rowspan="5"><p> <strong>ACUTE ILLNESS /
SYMPTOMS</strong></p>
<p> Abdominal Pain</p>
<p> Cardiac emergency (e.g., pain, arrest)</p>
<p> Conjunctivitis / eye irritation</p>
<p> Dehydration</p>
<p> Fever (i.e., &gt;100.4°F or 36°C)</p>
<p> Gastrointestinal <strong>specify:</strong></p>
<p> Nausea / vomiting</p>
<p> Bloody diarrhea</p>
<p> Watery diarrhea</p>
<p> Headache or migraine</p>
<p> Jaundice</p>
<p> Meningitis / encephalitis</p>
<p> Musculoskeletal pain (including joint, back)</p>
<p> Neurological (e.g., altered mental status or confused / disoriented,
syncope, stroke)</p>
<p> Oral / dental pain</p>
<p> Respiratory <strong>specify:</strong></p>
<p> Cough <strong>specify:</strong></p>
<p> Dry</p>
<p> Productive</p>
<p> With blood</p>
<p> Wheezing in chest</p>
<p> Pneumonia, suspected</p>
<p> Shortness of breath, difficulty breathing</p>
<p> Dermatologic <strong>specify:</strong></p>
<p> Rash</p>
<p> Infection</p>
<p> Infestation (e.g., lice, scabies)</p>
<p> Sore throat</p>
<p> Urinary pain (e.g., U.T.I.)</p></td>
<td colspan="5"><p> <strong>EXACERBATION OF CHRONIC DISEASE</strong></p>
<p> Cardiovascular <strong>specify:</strong></p>
<p> Hypertension</p>
<p>Congestive heart failure</p>
<p> Diabetes</p>
<p> Immunocompromised (e.g. HIV, lupus)</p>
<p> Respiratory <strong>specify:</strong></p>
<p> Asthma</p>
<p> COPD</p>
<p> Seizure</p></td>
</tr>
<tr class="even">
<td colspan="5"><p> <strong>MENTAL HEALTH</strong></p>
<p> Affective symptoms (e.g. overly anxious or depressed)</p>
<p> Drug/alcohol intoxication or withdrawal</p>
<p> Psychological evaluation</p>
<p> Suicidal thoughts or ideation</p>
<p> Violent behavior / threatening violence</p></td>
</tr>
<tr class="odd">
<td colspan="5"><p> <strong>OBSTETRICS / GYNECOLOGY</strong></p>
<p> Complication of pregnancy (e.g. premature bleeding, abdominal pain,
fluid leakage)</p>
<p> GYN condition not associated with pregnancy or post-partum
period</p>
<p> In labor with/without complication</p>
<p> Routine pregnancy check-up</p></td>
</tr>
<tr class="even">
<td colspan="5"> <strong>OTHER</strong></td>
</tr>
<tr class="odd">
<td colspan="5"><p> <strong>ROUTINE / FOLLOW-UP</strong></p>
<p> Medication refill Vaccination</p>
<p> Blood sugar check Wound care</p>
<p> Blood pressure check</p></td>
</tr>
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<td colspan="8"><p><u>Part V: WORKER/VOLUNTEER STATUS
INFORMATION</u></p>
<p> Did condition occur as a result of work (paid or volunteer)
involving disaster response ore restoration efforts?</p>
<p>Occupation / response role</p>
<p>Activity at time of injury/illness</p></td>
<td colspan="4"><u>Part IV: DISPOSITION</u> (circle one)</td>
</tr>
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