SESSION IV - Questionnaire # 1: Name of Hospital...................................................Country ............................. 

INJURY SURVEILLANCE SYSTEM IN EMERGENCY DEPARTMENT. 

CENTRAL AMERICA.CLINICAL REPORT

I. Identification 

Last Name First Name Register 

SEX Occupation AGE 

DAY MONTH YEAR BIRTHDAY 

minors 12 

years or 

younger 

DAY MONTH Y

E

A

R 

M F Education Year Completed

RESIDENCE 

DEPT MUNICIPALITY ADDRESS 

Place where 

the injury 

occurred 

DEPT MUNICIPALITY ADDRESS 

II- General Event Data (For every variable, check only one. ) 

Day and Hour: History

Mon Tue Wed Thur Fri Sat Sun 

DAY MONTH YEAR HOUR 

Day and Hour: EVENT

Mon Tue Wed Thur Fri Sat Sun 

INTENTIONALITY 

1-Unintentional (“accidents “ ) 

2-Self-inflicted (intentional :suicides or 

attempts ) 

3-Intentional (interpersonal violence, 

assaults ) 

8-Other____________________ 

9-Unknown 

PLACE 

Where were you when you were 

injured? 

1-Home 

2-School 

3-Street 

4-Work 

5- Bar, or similar 

8-Other_____________________ 

9-Unknown 

ACTIVITY 

What were you doing when you were 

injured?

1-Working 

2-Studying 

3-Sports 

4-Travelling 

5-Recreation/leisure 

6-Drinking alcohol 

8-Other_______________________ 

9-Unknown DAY MONTH YEAR HOUR MECHANISM OF INJURY (IES) (How was the injury sustained?) 

Previous Attention Yes No 

Where 

Attention in public hospital 

Yes No 

1-Transport Injury 

2-Sexual assault 

3-Falls: 

a) same level 

b) other level ( ........mts) 

4-Blunt force 

5-Stab/Cut 

6-Gunshot 

7-Fire/Smoke/heat 

 a) fire/smoke/flame 

 b) warm liquids 

 c) fireworks 

8-Choking/Hanging 

9-Drowning/near drowning 

10-Poisoning a) drugs........................... 

 b) pesticides..................... 

 c) Hydrocarbon 

11-Explosiona) landmines 

 b) other explosives ............ 

12- Bite a) person

 b) animal _____________ 

13-Electricity 

14- Natural Disaster____________ 

15- Contact with Foreign Body 

88-Other_____________________ 

99-Unknown

III-Injury Modules 

MOTOR VEHICLE RELATED INTERPERSONAL VIOLENCE or ASSAULTS 

Previous episode no yes No_____

SELF-INFLICTED 

Previous episode no yes No____

 ROAD USER 

(what was the role of 

the injured person ) 

1-Pedestrian 

2-Driver 

3-Passanger 

8-Other________ 

9-Unknown 

Safety elements 

1-seat belt (Y) ( N) ( U/K) 

2-helmet (Y) ( N) ( U/K) 

3-child car seat (Y) ( N) ( 

(U/K) 

MODE OF 

TRANSPORT 

1. Pedestrian 

2-Bicycle 

3-Motorcycle 

4-Car 

5-Pick-Up 

6-Truck 

7a-Bus 

7b-Microbús 

8-Cart/Animal 

9-Taxi 

88-Other_________ 

99-Unknown 

COUNTERPART 

1. Pedestrian 

2-Bicycle 

3-Motorcycle 

4-Car 

5-Pick-up 

6-Truck 

7a-Bus 

7b-Microbús 

8-Cart/Animal 

9-Taxi 

10-Fixed Object 

88-Other_________ 

99-Unknown 

 RELATIONSHIP 

PERPETRATOR TO 

THE VICTIM 

1-Partner or ex-partner 

2a-Parents 

2b-Step-parents 

3-Other relatives 

4-Friends/Known person 

5-Unknown person 

8-Other_____________ 

9-Unknown 

CONTEXT 

1-Quarrel/Fight 

2-Burglary or robbery 

3-Sexual Assault 

4-Gang Activity 

5-Family Violence/ 

 Domestic violence 

6-Lost [Stray??]Bullet 

8-Other____________ 

9-Unknown 

PRECIPITATING FACTORS 

1-Conflict with family 

2-Physical illness 

3-Psycological condition 

4-Financial problems 

5-Legal system encounters 

6-Death of family member 

7-Victim of sexual or physical 

abuse 

8-Conflict with partner/boyfriend 

9- Difficulties with school 

10- Unexpected pregnancy 

88-Other _______________ 

99-Unknown 

IV- Other Injury Data 

VICTIM / INJURED PERSON (If the driver was injured, complete this section)

ALCOHOL USE OTHER PSYCHOACTIVE SUBSTANCES 

1- No suspicion or evidence 

2- Yes, there is suspicion or evidence 

9- Unknown 

1- No suspicion or evidence 

2- Yes, there is suspicion, which is __________________________________ 

9- Unknown 

SEX OF 

PERPETRATOR 

1-Male 

2-Female 

9-Unknown 

V- Clinical Data 

ANATOMIC PLACE OF THE INJURY (IES ) 

(You can check more than one) SEVERITY 

1-Minor or superficial (e.g., 

bruises, minor cuts) 

2-Moderate, requiring some skilled 

treatment ( e.g., fractures, sutures ) 

3-Severe, requiring intensive 

medical/surgical management (e.g., 

internal hemorrhage, punctured 

organs, severed blood vessels)

DISPOSITION 

1-Treated and discharged 

2-Admitted to hospital 

3-Referred to other hospital. 

Name 

_________________________ 

4-Escape 

5-Voluntary abandonment 

6-Discharge condition 

 a) alive 

 b) died 

7. Unknown 

ICD X-DIAGNOSIS 

1-Head 

2-Face 

2-Neck 

3-Eyes 

4-Ears 

5-Nose 

6-Thorax 

7-Back 

8-Abdomen 

9-Pelvis/Genitals

10-Shoulder/Arm 

11-Elbow/Forearm 

12-Wrist/Hand/Fingers 

13-Hip/Thigh 

14-Knee/Legs 

15-Ankle/Feet/Toes 

16-Multiples 

88-Other__________

NATURE OF THE INJURY 

1-Laceration/Abrasion, 

2-Cut/Wound/Bite,Stab 

3- Systemic Organ Injury 

4-Strain/Sprain/Dislocation 

5-Fracture 

6-Burn 

7-Bruise/Contusion 

8-Trauma Brain 

88-Other________________ 

99- Unknown 

Physician 

ENTRY: No

: 
REASON FOR CONSULTATION: 

CURRENT DISEASES OR HEALTH PROBLEMS: 

TIME OF LAST MEAL HOUR OF ATTENTION 

PRE-EXISTING CONDITIONS 

PHYSICAL EXAM HR: RR: To: BP: INJURIES SCHEME 

PRESUMPTIVE DIAGNOSIS 

INITIAL INDICATIONS 

COMPLETED by (signature and stamp) SUPERVISOR (signature and stamp) AUTORIZATION (signature and stamp) 

PROCEDURES IMPLEMENTED 

Signature (person who conducted the procedure)____________________________

fdfdfdfdfd 

GLASGOW: Points 

WEIGHT 

______Kg. 

HEIGHT 

cm
SESSION IV - Questionnaire # 2. (from: MINISTERIO DE SALUD DE LA NACIÓN. REPUBLICA DE ARGENTINA) 

 A. Source of Report 

Facility code: Case number: Medical record number (optional): 

Interviewer’s name Date of consultation Time of consultation 

Informant: Injured  Other  specify who No informant  Date of Report to SINAVE 

B. Socio-demographic Information for the Injured Person 

Injured name and last name: Doesn’t know / doesn’t respond  

Sex: Male  Female  Age: Days  / Months  / Years  Birth date: / / 

Address: Street: No: Apt. No: Floor No: 

Town: Department: Province: Telephone: 

* Work? Yes , specify

_________________ 

No  What do you do?: Retired  Bondholder Housewife  Student  

 Unemployed Disabled  Other, specify_______________ 

Doesn’t know / 

doesn’t respond  

* Level of 

education 

None  Primary incomplete High school incomplete  Tertiary incomplete Univ. Incomplete 

 Primary complete  High school complete  Tertiary complete  Univ. complete  

Doesn’t know / 

doesn’t respond  

Incomplete data  

C. Incident-related Information 

When did the injury occur? / / Doesn’t know  At what time did the injury occur? Doesn’t know 

What day of the week? Monday Tuesday  Wednesday Thursday Friday Saturday Sunday Doesn’t know 

For CHILDREN AND OTHER: Person 

responsible during the event

Father Mother Other>18  Other< 18 Alone Doesn’t know / 

doesn’t respond  

Do you know the address or place where the 

injury occurred? No  Yes  Specify: 

Town: Department: Province: 

 D. Mechanism of the Injury 

 1. External cause or mechanism 

  Transport-related injury 

  Trapped, crushed between objects 

  Hit with blunt object 

  Fall-same level 

  Fall-from one to another level 

  Injury due to knife / blade / cutting 

 instrument 

  Gun or other firearm 

  Exposure to fire 

  Fireworks 

  Contact with heat source 

  Contact with hot substances 

  Exposure to electricity 

  Foreign body in eye or body cavity 

 (exclude aspiration) 

  Aspiration or choking 

  Suffocation and strangulation 

  Drowning and submersion 

  Traumatic contact with animal or plant 

  Dog bite 

  Earthquake 

  Other injury, specify:____________ 

 ________________________________ 

  Doesn’t know/ doesn’t respond 

 Poisoning or intoxication due to: 

  Drugs 

  Pesticides 

  Household products (nonpesticide) 

  Commercial or industrial products 

  Other substance, specify:__________ 

  Doesn’t know/ doesn’t respond 

2. Place of injury: 

 Public place or path or 

open or closed space 

 (go to 2a) 

 Home (go to 2b)

 Institution (go to 2c) 

 Other, specify: _______ 

 ______________________ 

 Doesn’t know/ doesn’t 

respond 

2a. Where in a public place did you get injured? 

  Road  Sports area 

  Avenue  Commercial area 

  Highway  industrial area 

  Sidewalk 

  Park or plaza  Other, specify ________ 

  Vacant lot _______________________ 

  Dam or river  Doesn’t know / Doesn’t respond 

  Irrigation channel 

  Off-road 

2b. Where in the home did you get injured?

  Patio / backyard  Stairs 

  Kitchen  Garage 

  Bedroom  Terrace 

  Bathroom  Swimming pool 

  Living/dining room  Other, specify: 

  Balcony ___________________ 

  Window  Doesn’t know / Doesn’t respond 

2c. In what kind of institution did you get injured?

  Day care center  Prison or reformatory 

  Kindergarten  Social club (non sports) 

  School  Theater 

  University  Other, specify: 

  Nursing home ___________________ 

  Hospital  Doesn’t know/Doesn’t respond

1 
3. What (kind of activity) were you doing when you were injured? 

(NOTE: if the activity requires use of personal protective equipment, complete section F)

 Paid manual work  Household chores  Other, specify ___________________ 

 Paid professional work  Activities of daily living _________________________________ 

 Transport to or from work  Practicing sports 

 Transport – non work-related  Recreation / playing  Doesn’t know/Doesn’t respond

4. INTENT OF THE EVENT 

  Intentional 

  Assault  Sexual assault (go to 4a)

  Suicide attempt 

  Suicide 

  Unintentional 

  Legal intervention 

  Undetermined intention 

  Other, specify________________________ 

  Doesn’t know/Doesn’t respond 

 

4a. This question is in reference to who injured you. You are not 

obligated to identify him/her. Do you know who injured you? 

  Knows but does not want to identify him/her 

  Knows and identifies him(her) 

  Partner or ex  Male friend/acquaintance  Other, specify:____ 

  Father  Female friend/acquaintance ______________ 

  Mother  Male stranger  Does not know 

  Stepfather  Female stranger  Does not respond 

  Stepmother 

E. Complete for Transportation-related Injuries only 

5. Type of injured: 

 Pedestrian 

 Passenger(go to 5a) 

 Driver 

 Other, specify: _________ 

 _______________________ 

 Doesn’t know/Doesn’t 

respond 

 Unknown 

5a. The passenger was in:

  Front seat 

  Rear seat 

  Standing 

 In the arms of other passenger 

  in front seat 

  in rear seat 

  Other, specify: _______ 

 _______________________ 

  Doesn’t know/Doesn’t 

respond 

5b. What kind of incident 

was it?: 

  Run over

  Two-vehicle collision 

  Collision with a fixed object 

  Collision with animal or 

 person 

  Overturned vehicle 

  Fall from vehicle in 

 movement 

  Other, specify:_______ 

 ______________________ 

  Doesn’t know/Doesn’t 

respond 

5c. Type of vehicle:

  Car 

  Truck 

  Bus 

  Trailer 

  Bicycle 

  Motorcycle/moped 

  Train 

  Wagon 

  Other, specify:______ 

 _____________________ 

  Doesn’t know/Doesn’t 

respond 

 

5d. Complete for collisions and run overs: 

Type of second vehicle or other party: 

  Car  Bicycle 

  Truck  Motorcycle/moped 

  Bus  Train 

  Trailer/wagon  Other, specify: 

 _______________ 

  Doesn’t know/Doesn’t respond 

5e. What were the weather conditions at the 

time of the injury? 

  Good weather  Natural light 

  Fog  Artificial light 

  Drizzle  Without light 

  Rain  Other, specify: ______ 

  Hail ____________________ 

  Snow  Doesn’t know/Doesn’t respond 

  Windy 

5f. Were there traffic 

signs where the injury 

occurred?

  Traffic light, YES 

  Traffic light, NO 

  Other, specify ____ 

 ______________________

  Doesn’t know/Doesn’t 

respond 

 5g. Were you wearing protective equipment at the time of the injury?

  Seat belt  Vehicle equipped with airbags  Other protective equipment, specify _________________ 

  Helmet  Did the airbags activate?  Doesn’t know/Doesn’t respond 

  Child safety seat/car seat  No protective equipment 

2 
3 

F. Complete for Activities that Require Use of Protective Equipment (examples: work-related, cooking, 

cleaning, sports and recreation activities; exclude transport)

6. Were you wearing protective equipment at the time of the injury? 

  Hemet  Gloves  None  Doesn’t know/Doesn’t respond 

  Protective boots  Mask  Other, specify ________________________________ 

G. Physical Examination 

7. Nature of injury(ies) (mark all that apply) 

  Wound  Spinal cord injury 

  Superficial injury / bruise  Internal injury 

  Excoriation  Muscular trauma 

  Sprain and strain  Dislocation 

  Crush injury 

  Fracture  Poisoning 

  Effect of foreign body  Burn and corrosion 

  Traumatic amputation  Freezing with tissue necrosis 

  Blood vessels trauma  Foreign body 

  Nerve trauma  Other, specify______ 

  Intracranial injury ______________________ 

  not specified 

8. Anatomic topography of the injury(ies) (mark all 

that apply) 

  Skull  Breast 

  Face  Abdomen 

  Eyes  Pelvis, perineum 

  Ears  Genitals 

  Nose  Thighs 

  Mouth  Legs 

  Neck  Feet 

  Arm  Toes 

  Forearm  Other, specify _____ 

  Hand ____________________ 

  Fingers  Not specified 

  Joints (specify)  Multiple injuries 

 ______________________ 

  Thorax, back 

  Thorax, chest 

10. Patient disposition 

  Outpatient 

  Observation in unit 

  Hospitalization 

  Referred to______________________ 

  Against medical advice 

  Died before admission into unit 

  Died in unit 

 9. Injury severity (use the CDC Practical Injury 

Severity Score, if possible): 

 

 CDC Practical Injury Severity Score: 

  Mild  Moderate  Severe

 

 Revised Trauma Score (RTS) _____________ 

 

 Index of Pediatric Trauma (IPT) _______________

 Grade of Poisoning Severity Score (PSS) 

  Asymptomatic  Mild  Moderate 

  Severe  Fatal 

 Degree of burn-related injuries: 

  1o  2o  3o 

 Percent of surface burned:_______________%

11. Clinical evidence of alcohol and/or illicit drug use 

 Alcohol  Yes  No  Uncertain 

 Illicit drugs  Yes  No  Uncertain

12. Clinical diagnosis of the injury:___________________________________________________________________________ 

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________ 

13. Diagnosed concurrent/co-morbid condition(s): _____________________________________________________________
4 

 H. Optional Module 1. Injuries of the Oral Cavity (to be collected by dentist only) 

 14. If the injury occurred in a school, specify where: 

  Classroom 

  Physical education 

  Recess 

  Doesn’t know/Doesn’t respond 

15. What kind of object (or weapon) caused the injury? 

  Stick 

  Stone 

  Other, describe_______________ 

 __________________________ 

  Doesn’t know/Doesn’t respond 

16. Topography of the injury 

 One tooth 

 Two or more teeth 

  Right cheek 

  Left cheek 

  Both cheeks 

  Superior lip 

  Inferior lip 

  Both lips 

  Tongue 

  Gum 

17. Dentition phase 

  Temporary 

  Permanent 

  Mixed 

18. Nature of the injury affecting: 

 Teeth: Periodontal tissue : Support bone: Gums and oral mucosa: 

 Fissure  Concussion  Conminution  Contusion 

 Noncomplicated coronary fracture  Lateral dislocation  Fracture of the alveolar wall  Abrasion 

 Noncomplicated coronoradicular fracture  Intrusion  Fracture of the alveolar process  Laceration 

 Radicular fracture (any type)  Avulsion  Fracture of the maxilar or mandibular bone 

 Complete coronoradicular fx (inc pulp)  Extrusion