International Classification of

External Causes of Injuries

Short Version (Short ICECI)

Data Collection Form

for

A Pilot Study

Proposed by

The National Center for Injury Prevention and Control (NCIPC)

Surveillance Working Group

Centers for Disease Control and Prevention (CDC)

Atlanta, Georgia

Prepared by

J. Lee Annest, PhD (jla1@cdc.gov)

Judy Conn, MS

Chet Pogostin, DVM

Office of Statistics and Programming, NCIPC, CDC

Lois Fingerhut, MA

Donna Pickett, RRA, MPH

Collaborators and Consultants, NCHS, CDC

October 21, 1999
International Classification of External Causes of Injuries

Short Version (Short ICECI) Data Collection Form – Pilot Study

Instructions: This form was designed to record

information about circumstances of an injury

incident for injured persons treated in an

emergency department or a similar health care

setting. Ideally this form could become part of

the ED record for the patient. Some instructions

for completing the form are given in italics. For

further details about how an injury is defined

and how to code each of the components given

below, please see the instruction manual and

coding guidelines.

1. Was the injury incident work-related (i.e., occur on

the job) or not? (Check One)

❏ 1 Work-related

❏ 2 Not work-related

❏ 9 Not recorded/unspecified

2. Where did the injury occur? (Check One)

❏ 01 Home/mobile home

❏ 02 Residential institution

❏ 03 Farm/ranch

❏ 04 Street/highway

❏ 05 Trade and service area

❏ 06 Industrial/construction area

❏ 07 School/educational area

❏ 08 Other public building

❏ 09 Sports and athletic area

❏ 88 Other specified

❏ 99 Not recorded/unknown

3. What type of activity was the patient doing at the

time of injury? (Check One)

❏ 1 Sports

❏ 2 Leisure

❏ 3 Traveling

❏ 4 Paid work

❏ 5 Unpaid work

❏ 6 Educational activity

❏ 7 Vital activity

❏ 8 Other specified

❏ 9 Not recorded/unspecified

Type of Activity When Injured

Locale of Injury Incident

Intent of Injury

If your response to Question 4. was “Assault” please

answer Questions 4a. and 4b., otherwise go to Question 5.

4a. What was the relationship of the perpetrator to

 the patient? (Check One)

❏ 01 Spouse or partner (includes spouse, partner,

 ex-spouse, ex-partner)

❏ 02 Parent

❏ 03 Other relative

❏ 04 Unrelated care giver

❏ 05 Acquaintance or friend

❏ 06 Official/legal authorities

❏ 07 Multiple perpetrators

❏ 08 Stranger

❏ 88 Other specified persons

❏ 99 Not recorded/unknown

4b. What was the reason for the assault?

 (Check all that apply)

❏ 1 Altercation

❏ 2 During illegal acquisition of money or

 property (includes completed or attempted)

❏ 3 Drug-related

❏ 4 Sexual assault

❏ 5 Gang-related

❏ 8 Other specified

❏ 9 Not recorded/unknown

4. Did the injury result from an unintentional event or

intentional act? (Check One)

❏ 1 Unintentional

❏ 2 Intentionally self-inflicted

❏ 3 Assault, confirmed or suspected — Injury

 purposely inflicted by another person

(Answer Questions 4a and 4b)

❏ 4 Legal intervention — Injured by police or other

 authorities during law enforcement

❏ 5 Operations of war and civil insurrection

❏ 9 Not recorded/undetermined

 Type of Incident

Page -1-

Coder I.D.

Hospital I.D.

Patient I.D.

Treatment Date:

 (MM/DD/YYYY)

Patient Information:

 Age ( in years):

 Sex: ❏ 1 Male ❏ 2 Female ❏ 9 Unknown

 Race: ❏ 1 White ❏ 2 Black ❏ 3 Other ❏ 9 Unknown

 Ethnicity: ❏ 1 Hispanic ❏ 2 Non-Hispanic ❏ 9 Unknown

Coding

 Time

 (in minutes)
International Classification of External Causes of Injuries

Short Version (Short ICECI) Data Collection Form – Pilot Study

5. What was the mechanism or cause of injury?

(Check all that apply)

❏ 01 Motor vehicle

 (Answer Questions 5.1.a. through 5.1.d.)

❏ 02 Pedestrian-vehicle crash

 (Answer Questions 5.1.a. and 5.1.d.)

❏ 03 Motorcycle

 (Answer Questions 5.1.a, 5.1.c., and 5.1.d.)

❏ 04 Pedal cycle

 (Answer Questions 5.1.a. and 5.1.d.)

❏ 05 Struck by/against or crushed

 (Answer Questions 5.1.e and 5.1.f)

❏ 06 Fall

❏ 07 Gunshot, firearm-related (excludes nonpowder guns)

 (Answer Question 5.1.g)

❏ 08 Stab/cut/pierce (Answer Question 5.1.h)

❏ 09 Fire/burn (Answer Question 5.1.i)

❏ 10 Smoke inhalation

❏ 11 Poisoning (Answer Question 5.1.j)

❏ 12 Near-drowning/drowning/submersion

❏ 13 Foreign body

❏ 14 Overexertion

❏ 15 Other specified mechanism

 (Answer Question 5.1.k.)

❏ 16 Adverse effects of therapeutic use of drugs

❏ 17 Adverse effects of surgical and medical care

❏ 99 Not recorded/undetermined

 Mechanism of Injury

If one of your responses to Question 5. was “Motor

vehicle,” please answer Question 5.1.b., otherwise go

to Question 5.1.c.

5.1.b. What type of vehicle was the patient riding in?

 (Check One)

❏ 1 Automobile

❏ 2 Pickup truck or van

❏ 3 Heavy transport vehicle

❏ 4 Bus

❏ 5 3-wheel motor vehicle

❏ 6 Other specified

❏ 9 Not recorded/unknown

Page -2-

5a. If more than one mechanism was selected in

 Question 5, which one is the immediate cause

 of the most severe injury being treated?

 (Record the number given next to the mechanism

 in Question 5.) ❏

If one of your responses to Question 5. was “Motor

vehicle,” “Pedestrian-vehicle crash,” “Motorcycle,”

or “Pedal cycle,” please answer Questions 5.1.a. through

5.1.d., otherwise go to Question 5.1.e.

5.1.a. Was the crash traffic-related or not? (Check One)

❏ 1 Traffic (occurs on a public highway/street/road)

❏ 2 Nontraffic (occurs in any place other

 than a public highway/street/road)

❏ 9 Not recorded/unknown

If one of your responses to Question 5. was “Motor

vehicle” or “Motorcycle,” please answer Question 5.1.c.,

otherwise go to Question 5.1.d.

5.1.c. What was the patient doing in or on the motor

 vehicle or on the motorcycle? (Check One)

❏ 1 Driver

❏ 2 Passenger

❏ 3 Person boarding or alighting

❏ 4 Person on outside of motor vehicle

❏ 9 Not recorded/unknown

If one of your responses to Question 5. was “Motor

vehicle,” “Pedestrian-vehicle crash,” “Motorcycle,”

or “Pedal cycle,” please answer Questions 5.1.d.,

otherwise go to Question 5.1.e.

5.1.d. What was the counterpart to the crash? (Check One)

❏ 01 Automobile

❏ 02 Pickup truck or van

❏ 03 Heavy transport vehicle

❏ 04 Bus

❏ 05 3-wheel motor vehicle

❏ 06 Motorcycle

❏ 07 Railway train/vehicle

❏ 08 Pedal cycle

❏ 09 Pedestrian

❏ 10 Animal or animal-drawn vehicle

❏ 11 Fixed or stationary object

❏ 12 No counterpart (rollover or overturning)

❏ 88 Other specified

❏ 99 Not recorded/unknown

Coder I.D.

Hospital I.D.

Patient I.D.

Treatment Date:

 (MM/DD/YYYY)
International Classification of External Causes of Injuries

Short Version (Short ICECI) Data Collection Form – Pilot Study

Coder I.D.

Hospital I.D.

Patient I.D.

Treatment Date:

 (MM/DD/YYYY)

If one of your responses to Question 5. was “Struck by/

against or crushed,” please answer Questions 5.1.e. and

5.1.f., otherwise go to Question 5.1.g.

5.1.e. What was the source of the force applied?

 (Check One)

❏ 1 Human

❏ 2 Animal

❏ 3 Inanimate object or force

❏ 9 Not recorded/unknown

5.1.f. What type of force was applied? (Check One)

❏ 1 Struck by

❏ 2 Crushed by

❏ 3 Striking against

❏ 9 Not recorded/unknown

Page -3-

If one of your responses to Question 5. was “Gunshot,”

please answer Question 5.1.g., otherwise go to Question

5.1.h.

5.1.g. What was the type of firearm used? (Check One)

❏ 1 Handgun

❏ 2 Rifle

❏ 3 Shotgun

❏ 4 Larger firearm

❏ 9 Not recorded/unknown

If one of your responses to Question 5. was “Stab/cut/

pierce,” please answer Question 5.1.h., otherwise go to

Question 5.1.i.

5.1.h. What type of stabbing instrument, weapon, or object

 was involved? (Check One)

❏ 1 Knife

❏ 2 Sharp instrument/tool other than knife

❏ 3 Sharp glass

❏ 8 Other specified

❏ 9 Not recorded/unknown

If one of your responses to Question 5. was “Fire/burn,”

please answer Question 5.1.i., otherwise go to Question

5.1.j.

5.1.i. What type of burn was it? (Check One)

❏ 01 Fire/flame

❏ 02 Hot object

❏ 03 Hot liquid

❏ 04 Steam

❏ 05 Chemical

❏ 88 Other specified

❏ 99 Not recorded/unknown

If one of your responses to Question 5. was “Poisoning,”

please answer Question 5.1.j., otherwise go to Question

5.1.k.

5.1.j. What type of poisoning was it? (Check One)

❏ 1 Drug (excludes alcohol)

❏ 2 Alcohol

❏ 3 Chemical (includes solid, liquid, gas or vapor,

 excludes drugs and alcohol)

❏ 8 Other specified

❏ 9 Not recorded/unknown

 Continue on Page 4 with Question 5.1.k
International Classification of External Causes of Injuries

Short Version (Short ICECI) Data Collection Form – Pilot Study

Coder I.D.

Hospital I.D.

Patient I.D.

Treatment Date:

 (MM/DD/YYYY)

Safety Equipment Use

6. Was information given about safety equipment used or

deployed at the time of injury? (Check One)

❏ 1 Yes

❏ 2 No

If your response to Question 6. was “Yes,” please answer

Question 6a., otherwise go to Question 7.

6a. Which of the following types of safety equipment were

 described to be (in/not in) use or deployed at the time

 of injury? (Check all that apply)

A=In use or deployed B=Not in use or deployed C=Unknown

 A B C

❏ ❏ ❏ 01 Shoulder belt

❏ ❏ ❏ 02 Lap belt

❏ ❏ ❏ 03 Seat belt, not otherwise specified

❏ ❏ ❏ 04 Driver’s front airbag deployed

❏ ❏ ❏ 05 Passenger’s front air bag deployed

❏ ❏ ❏ 06 Front air bag deployed,

 not otherwise specified

❏ ❏ ❏ 07 Side air bag deployed

❏ ❏ ❏ 08 Air bag deployed,

 not otherwise specified

❏ ❏ ❏ 09 Child safety seat

❏ ❏ ❏ 10 Helmet

❏ ❏ ❏ 11 Eye protection

❏ ❏ ❏ 12 Protective clothing

❏ ❏ ❏ 13 Personal flotation device

❏ ❏ ❏ 88 Other protective gear

8. Please briefly describe the circumstances of the injury incident. (Please Print)

Page -4-

7. Please describe up to three consumer product(s) that were

involved in the injury incident. (Please Print)

1.

2.

3.

If one of your responses to Question 5. was “Other

specified mechanism,” please answer Question 5.1.k.,

otherwise go to Question 6.

5.1.k. What was the other specified mechanism or

 cause of injury? (Check One)

❏ 01 Railway/streetcar (occupant) in motor

 vehicle crash

❏ 02 Other railway/streetcar transport

❏ 03 Water transport

❏ 04 Air transport

❏ 05 Thrown or fallen from animal or

 animal-drawn vehicle (noncollision)

❏ 06 Other transport (not elsewhere specified)

❏ 07 Inhalation/ingestion of food (blocking airway)

❏ 08 Inhalation /ingestion of other objects

 (blocking airway)

❏ 09 Hanging or strangulation

❏ 10 Suffocation by plastic bag, sheet, cloth

 or other material

❏ 11 Entrapment in closed space

❏ 12 Venomous bite or sting

❏ 13 Human bite

❏ 14 Dog bite

❏ 15 Bite by animal other than dog

❏ 16 Sting (other than venomous animal or plant)

❏ 17 Fireworks explosion

❏ 18 Explosive blast (other than fireworks)

❏ 19 BB or pellet gunshot

❏ 20 Other firearm (other than gunshot)

❏ 21 Lightning

❏ 22 Electrical current (excludes lightning)

❏ 23 Radiation

❏ 24 Welding

❏ 25 Machinery

❏ 26 Exposure to excessive natural heat

❏ 27 Exposure to excessive natural cold

❏ 28 Sunlight

❏ 29 Natural disaster

❏ 88 Other specified, not elsewhere classified