Surveillance tool for Health Facility

Q. No.	Question	Data entry rule	Values Assigned		Req	Skip Pattern
	FORM I
A	PERSONAL IDENTIFICATION
1	Centre Code	Dropdown	Chennai	1	Yes
			Chitoor	2
			Jaipur	3
			Delhi	4
			TehriGarhwal	5
2	Hospital Code	Dropdown	Public sector health facility	1	Yes
			Private sector health facility	2
3	Serial number	Numeric Box	0001–9999		Yes
4	User code	Numeric Box	01–99		Yes
5	IRIS ID	Auto-generated. Should not allow entering or editing the field.	Will constitute the Centre code, Hospital code, User code and Serial No.		Yes	“Auto generated field” appears if we try to enter.
			For e.g. IRIS:ID:11010005 means case belongs to Chennai, Public hospital and 1st user and is in the fifth case in serial order
Once IRIS ID is generated it should be displayed as the header of the form in display. One can save the form only after filling up to IRIS ID, before which the form cannot be saved and should be discarded. Every form should be saved with its IRISID as name.
6	Medical Record Number (Inpatient/Out Patient Number)	Text Box			Yes
7	AR Number (Accident Register number)	Numeric box
8	Admission Date	Calendar pick	dd/ mm/ yyyy		Yes
9	Admission Time	Time pick	hh:mm
10	Respondent Name	Text Box (Alpha only)			Yes
11	How are you related to the injured?	Dropdown	Self	1	Yes	If 1 is selected Skip Q12 to 14. If 997 go to Q12, else Skip Q12.
			Family member	2
			Friend	3
			Driver	4
			Co-passenger	5
			Unknown passerby	6
			Others	997
12	Specify Relationship with injured	Text Box
13	Do you have a mobile number? (Respondent)	Radio button	Yes	1	Yes	If 1 is selected go to Q14 else skip Q14.
			No	2
			Unknown	998
14	Enter Mobile Number of the Respondent	Numeric Box	Add zero (0) before 10 digit mobile number		Yes
15	What is the name of the Injured?	Text Box (Alpha only)			Yes
16	Do you have mobile number? (Injured)	Radio button	Yes	1	Yes	If 1 is selected go to Q17 else skip Q17.
			No	2
			Unknown	998
17	Enter Mobile number of the injured	Numeric Box	Add zero (0) before 10 digit mobile number		Yes
18	Do you know the address of the injured?	Radio Button	Yes	1	Yes	If 1 is selected go to Q19 else skip Q 19 to 22.
			No	2
19	State of Injured	Dropdown	All States Of India		Yes
20	District of Injured	Dropdown	Districts of selected state		Yes
21	Taluk of Injured	Dropdown	Taluk of selected District		Yes
22	Village/Area of Injured	Text Box
B	SOCIO DEMOGRAPHICAL DETAIL
1	Age of Injured	Radio button (Text box is enabled based on Q1. If 1 is selected Text box1and unknown is enabled, If 2 is selected Text box2 and unknown is enabled)	< 1year (In Months) – Text box1		Yes	B01_AgeYr s is greater than or equal to 5 show Q4, Q5 or Skip Q4, Q5
			>1 year (In Years) Text – box2
			Unknown	998
2	Gender of Injured	Dropdown	Male	1	Yes
			Female	2
			Transgender	3
3	Educational status of the Injured	Dropdown	Illiterate	1	Yes
			Primary	2
			High School	3
			Higher Secondary	4
			Diploma/Certified course	5
			Graduate and above	6
			Unknown	998
4	Occupation of the Injured	Dropdown	Business	1	Yes	If 997 go to Q5, else Skip Q5.
			Self Employed/Medium Business	2
			Professional/Executive/Managers	3
			Employee (Govt./Private)	4
			Skilled Manual (Artisians, Agriculture, Fishery, Forestry)	5
			Unskilled Manual (Labour)	6
			Home maker	7
			Student	8
			Unemployed	9
			Others	997
			Unknown	998
5	Specify Occupation of the injured	Text Box
C	ACCIDENT IDENTIFICATION DETAILS
1	Date of accident	Date pick	dd/mm/yyyy		Yes
2	Time of accident	Time pick (Scroll)	hh:mm		Yes
3	State of accident	Dropdown	All States Of India		Yes
4	District of accident	Dropdown	District of selected state		Yes
5	Taluk of accident state	Dropdown	Taluk of Selected District		Yes
6	Village/Town of accident site	Text Box			Yes
7	Nearest landmark of accident site	Text Box	(GIS mapping-insert map)
8	What is the type of accident?	Dropdown	Self-fall/Skid	1	Yes	If 997 go to Q9, else Skip Q9.
			Crash with pedestrian	2
			Crash with parked vehicle	3
			Crash with fixed obstacle	4
			Crash with non-fixed obstacle	5
			Crash between two
			vehicles	6
			Crash with two or more
			vehicles	7
			Crash with animal	8
			Others	997
			Unknown	998
9	Specify Type of Accident	Text Box
10	What was the weather condition at the time of accident?	Dropdown	Clear	1	Yes	If 997 go to Q11, else Skip Q11.
			Hot/dry weather	2
			Rainy	3
			Fog/Mist/Smoke/Smog	4
			Sever winds	5
			Landslide	6
			Snow	7
			Others	997
			Unknown	998
11	Specify weather condition	Text Box			Yes
12	What was the light condition at the time of accident?	Dropdown	Excess Light	1	Yes
			Sufficient Light	2
			Partial light	3
			Insufficient Light	4
			Unknown	998
13	Has FIR been lodged	Dropdown	Yes	1	Yes	If 1 go to Q14 else Skip Q14
			No	2
			Unknown	998
			Not applicable	996
14	FIR Number	Text box
D	ROAD RELATED DETAILS
1	What is the type of road of the accident site?	Dropdown	National highway	1	Yes
			State highway	2
			Major District Roads (MDR)	3
			Other District Roads(ODR)	4
			Village Roads (VR)	5
			Unknown	998
2	What is the sub-type of the accident site	Multiple Choice	One way road	1	Yes	If any 6,7,8,11,12 selected go to Q3 else Skip Q3 and Q4.
			Two way road	2
			Single lane	3
			Two lane road	4
			Four or above lane road	5
			Cross Road	6
			Round about	7
			Railway crossing	8
			Curve road/Blind curve	9
			Gradient road	10
			T or Staggered junction	11
			Multiple Junction	12
			Unknown	998
3	Traffic Controlled by	Multiple choice	Traffic signal/Rail road barrier	1	Yes	If 997 is selected go to Q4 else Skip Q4.
			Traffic personnel/Railway personnel	2
			Concerned Institute/organization personnel	3
			Public Volunteer	4
			Uncontrolled	5
			Others	997
			Unknown	998
4	Specify Traffic Control	Text Box
5	How were the road conditions at the accident site	Dropdown	Safe	1	Yes	If 997 is selected go to Q6 else Skip Q6.
			Slippery (Wet/Oily)	2
			Muddy	3
			Rutted/Pot holed	4
			Flooded	5
			Snow	6
			Work under progress	7
			Others	997
			Unknown	998
6	Specify Road Condition	Text Box
7	Do you know the Speed limit of the Road?	Dropdown	Yes	1	Yes	If 1 is selected go to Q8 else Skip Q8.
			No	2
			Not applicable	996
8	Enter the Speed Limit	Numeric Box			Yes
E	VEHICLE INFORMATION
1	How many vehicles involved in the crash?	Numeric Box			Yes
The following Questions Q2 to Q13 should repeat based on the number entered in Q1. The variable name should change with the number. For example, if 3 is entered in Q1, 3 times the Questions 2 to 13 will be repeated each time variable name number will change (Eg: E02_TypeVehcl_1 first time, E02_TypeVehcl_2 Second time and E02_TypeVehcl_3 Third time).
Each set should have the label “Vehicle (number-1) Details”, the number is based on the number of times the Question set is repeated. For example, first set will have the label “Vehicle 1 Detail”, Second set will have the label “Vehicle 2 Detail” and so on up to 5.
2	What was the type of vehicle involved in the accident?	Dropdown	Bicycle/Cycle rickshaw	1	Yes	If 997 is selected go to Q3 else Skip Q3.
			Bullock cart	2
			Two wheeler geared	3
			Two wheeler non-geared	4
			Auto rickshaw	5
			Car	6
			Tempo traveler/Van/City ride	7
			Bus/Mini Bus	8
			Trucks/Tra ctors	9
			Lorry	10
			Others	997
			Unknown	998
3	Specify Vehicle:	Text Box
4	What is the special function of the vehicle?	Dropdown	Personnel private vehicle	1	Yes	If 997 is selected go to Q5 else Skip Q5.
			Public passenger vehicle	2
			Private passenger vehicle	3
			Goods vehicle (Public/Co mmercial)	4
			Govt. official vehicle	5
			Others	997
			Unknown	998
5	Specify vehicle function	Text Box
6	Vehicle manoeuvre (action taken by vehicle immediately before it become involved in crash)	Dropdown	Normal straight driving	1	Yes	If 997 is selected go to Q7 else Skip Q7.
			Changing lane	2
			Reversing	3
			Turning	4
			Over taking	5
			Slowing/st opping/mo ving off	6
			Parked	7
			Driving off the lane/road	8
			Others	997
			Unknown	998
7	Specify vehicle manoeuvre	Text Box
8	What is the driving licensure status of the vehicle driver?	Dropdown	Present Valid	1	Yes
			Present Invalid	2
			Absent	3
			Learners License	4
			Unknown	998
			Not applicable	996
9	Was the vehicle over speeding at the time of accident?	Dropdown	Yes	1	Yes
			No	2
			Unknown	998
10	What was the driving quality of the vehicle at the time of accident?	Dropdown	Safe driving	1	Yes
			Distracted Driving	2
			Uncontrolle d Driving	3
			Sleepless/worn out driving	4
			Unsafe driving due to health	5
			Impairment Unknown	998
F	PERSON RELATED DATA
1	What type of road user was the injured person?	Dropdown	Driver	1	Yes	If 1 and 998 is selected skip Q2 and Q3. If 2 is selected go to Q2 and skip Q3. If 3 is selected go to Q3 and skip Q2
			Passenger	2
			Pedestrian	3
			Unknown	998
2	What is the seating position of the passenger	Dropdown	Front	1	Yes
			Rear middle	2
			Rear side	3
			On the roof	4
			Standing inside/on vehicle	5
			Foot Board	6
			Pillion rider (sitting behind in two wheeler)	7
			Unknown	998
3	Pedestrian activity at the time of accident?	Dropdown	Crossing road	1	Yes
			Standing middle of the road	2
			Walking/standing along shoulder of the road	3
			Walking/standing in the footpath	4
			Unknown	998
4	What were the safety precautions taken by injured person at the time of accident?	Multiple choice	Seat belt worn	1	Yes	If 1 or 2 in Q1 in session F and 3 or 4 in Q2 in session E is selected enable only options 2, 4, 996 and 998 If 1 or 2 in Q1 in session F and 5, 6, 7 and 8 in Q2 in session E is selected then enable only options 1, 3, 4, 996and 998 If 3 is selected in Q1 in session F then enable only options 4, 5, 996 and 998. If 1 or 2 in Q1 in session F and 1, 2, 9, 10, 997 and 998 in Q2 in session E enable options only 4, 998 and 996.
			Helmet worn	2
			Airbag present in vehicle	3
			Followed traffic signal	4
			Used Zebra crossing	5
			Unknown	998
			Not applicable	996
5	Who were Drunken/consumed alcohol during accident?	Multiple choice	Driver of the injured vehicle	1	Yes	If 1 in Q5 and 1 in Q1 is selected or 2 in Q5 and 2 in Q1 is selected or 5 in Q5 and 3 in Q1 is selected Go to Q6 else skip Q6.
			Passenger/Co-passenger of the injured vehicle	2
			Driver of the counterpart vehicle	3
			Passenger/Co-passenger of the counterpart vehicle	4
			Pedestrian	5
			Unknown	998
6	Blood Alcohol level of the injured	Numeric Box
7	Who used Mobile phone during accident?	Multiple choice	Driver of the injured vehicle	1	Yes
			Driver of the counterpart vehicle	2
			Pedestrian	3
			Unknown	998
G	PRE-HOSPITAL ADMISSION DATA
1	What was the time duration taken for rescue efforts after the accident happened?	Time Format	hh:mm		Yes
2	How was the injured person rescued?	Dropdown	Self	1	Yes	If 997 is selected go to Q3 else skip Q3.
			Known Person (Friends/Relatives)	2
			Driver/Passenger/Co-Passenger	3
			Local People/Passerby	4
			Police	5
			Army	6
			Disaster Response Force (State/National)	7
			Others	997
			Unknown	998
3	Specify how was the injured person rescued	Text Box				.
4	What was the reason for delay in rescuing the injured person?	Dropdown	Noticed Late	1	Yes	If 997 is selected go to Q5 else skip Q5.
			Late Information given to rescue team/Emergency transport	2
			Access difficulty (Difficult terrain or difficult to access site)	3
			Weather conditions	4
			Emergency Transport Vehicle arrived late	5
			Others	997
			Unknown	998
			Not applicable	996
5	Specify the reason for delay in rescuing the injured person	Text Box
6	How was the injured person taken from the accident site to the transport vehicle?	Dropdown	Stretcher	1	Yes
			Sheets	2
			Hold by 2–4 peoples	3
			Carried by people on their back	4
			Others	997
			Unknown	998
			Not applicable	996
7	Specify how was the injured person taken from the accident site to the transport vehicle	Text Box
8	Was the injured person given first aid?	Dropdown	Yes	1	Yes	If 1 go to Q9 or skip Q9, Q10, Q11 and Q12.
			No	2
			Unknown	998
9	Where was the first aid given?	Dropdown	At the accident site	1	Yes	If 997 go to Q10 else skip Q10.
			Nearby Govt. Hospital	2
			Nearby Private clinic	3
			Ambulance	4
			Others	997
			Unknown	998
10	Specify where was the first aid given	Text Box
11	Who gave the first aid?	Dropdown	Health worker/Nurse	1	Yes	If 2,3,4 is selected in Q9 disable options 4,5 and 6. If 997 go to Q12 else skip Q12
			Ambulance technician	2
			Doctor	3
			Public	4
			Police	5
			Family members	6
			Others	997
			Unknown	998
12	Specify who gave the first aid	Text Box
13	How was the injured person transported to health facility?	Dropdown	Self	1	Yes	If 997 go to Q14 else skip Q14.
			Government Ambulance	2
			Private Ambulance	3
			Commercial passenger vehicle	4
			Commercial goods vehicle	5
			Private vehicle	6
			Govt. Official vehicle	7
			Others	997
			Unknown	998
14	Specify how was the injured person transported to health facility	Text Box
15	Number of hospitals/health facilities visited before attending the registering hospital	Numeric Box			Yes	If 0 skip Q16, Q 17, Q18, Q19, Q20, Q21, Q22 and Q23. If 1 Skip Q16 If >1 go to Q16.
16	What was the first referral hospital?	Dropdown	Primary health care facility	1
			District Government Hospitals	2
			Other Government Hospitals	3
			Private hospitals	4
			Private nursing home	5
			Unknown	998
17	What was the Last referral hospital?	Dropdown	Primary health care facility	1	Yes
			District Government Hospitals	2
			Other Government Hospitals	3
			Private hospitals	4
			Private nursing home	5
			Unknown	998
18	Last Referral hospital State	Dropdown	All States in India		Yes
19	Last Referral hospital District	Dropdown	District of selected state		Yes
20	Last Referral hospital Taluk	Dropdown	Taluk of Selected District		Yes
21	Last Referral hospital Village/Town/Area	Text Box	(GIS mapping-insert map)		Yes
22	Reason for shifting from the referral hospital?	Dropdown	Not equipped for the treatment required	1	Yes	If 997 go to Q23 else skip Q23.
			Specialist doctors not available	2
			Bed not available	3
			Patient’s desire	4
			Others	997
			Unknown	998
23	Specify reason for shifting from the referral hospital	Text Box
H	AMBULACNE DETAILS (This section appears only if 1 or 2 is selected in Q12 of G section else skip)
1	Whether ambulance details available?	Radio button	Yes	1	Yes	If 2 is selected skip rest questions in this section else go to Q2.
			No	2
2	Date of the call received by ambulance personnel regarding the accident? (Date)	Calendar Format	dd/mm/yyyy		Yes
3	Time of the call received by ambulance personnel regarding the accident? (Time)	Time Format (Scroll)	hh:mm
4	Date - ambulance reached the accident site? (Date)	Calendar Format	dd/mm/yyyy		Yes
5	Time-ambulance reached the accident site? (Time)	Time Format (Scroll)	hh:mm
6	Date patient dropped at the hospital? (Date)	Calendar Format	dd/mm/yyyy		Yes
7	Time patient dropped at the hospital? (Time)	Time Format (Scroll)	hh:mm
8	How was the patient managed in the transport vehicle during the transport from accident site to hospital?	Multiple choice	CPR	1		If 997 go to Q9 else skip Q9.
			Electrical defibrillation	2
			Maintained airway	3
			Bleeding controlled	4
			IV Fluid	5
			IV Blood	6
			IV / IM Drugs	7
			Positioning of the patient	8
			Others	997
			Not applicable	996
9	Specify how was the patient managed in the transport vehicle	Text Box
10	Ambulance has the facility to record and monitor	Multiple choice	Pulse rate	1	Yes	If 994 or 998 skip rest questions. If 1, 2, 3, 4 and 5 is yes showQ11, Q12 and Q13, Q14, Q15 and Q16 respectivel y. For Options not selected hide the respective questions.
			BP	2
			Respiratory Rate	3
			Oxygen Saturation	4
			GCS	5
			None	994
			Unknown	998
11	Ambulance pulse rate	Numeric box1 (First)
		Numeric box2 (Last)
12	Ambulance Systolic Blood Pressure	Numeric box1 (First)
		Numeric box2 (Last)
13	Ambulance Diastolic Blood Pressure	Numeric box1 (First)
		Numeric box2 (Last)
14	Ambulance Respiratory Rate	Numeric box1 (First)
		Numeric box2 (Last)
15	Ambulance oxygen saturation	Numeric box1 (First)
		Numeric box2 (Last)
16	Ambulance Glasgow Coma Scale (GCS)	Numeric box1 (First)
		Numeric box2 (Last)
I	CLINICAL DETAILS (On the day of admission)
1	What was status of injured at the time of admission	Dropdown	Unconscious	1	Yes
			Conscious	2
			Unknown	998
2	Co morbidity Level	Dropdown	Healthy	1
			Non-Limiting	2
			Limiting	3
			Constant Threat to life	4
			Unknown	998
			Not documented	999
3	Pulse rate	Numeric box
4	Systolic BP	Numeric box
5	Diastolic BP	Numeric box
6	Respiratory rate	Numeric box
7	Oxygen Saturation	Numeric box
8	Glasgow Coma Scale (GCS)	Numeric box
	FORM II
J	CLINICAL, TREATMENT AND OUTCOME DETAILS discharge/ death/ abscond / referral of the patient) (Follow up-to be submitted during
1	User code	Numeric Box	Jan-99		Yes
2	IRIS ID		Dropdown of the User code synced IRIS-ID		Yes
3	What are the parts of the body injured	Dropdown	Head	1
			Neck	2
			Thorax	3
			Abdomen, lower back, lumbar spine and pelvis	4
			Shoulder and upper arm	5
			Elbow and forearm	6
			Wrist and hand	7
			Hip and thigh	8
			Knee and lower leg	9
			Ankle and foot	10
			Multiple body regions	11
			Injuries to unspecified part of trunk limb and body	12
4	What was the nature of injuries sustained	Dropdown	Superficial injury	1
			Open wound	2
			Fracture	3
			Dislocation, sprain and strain	4
			Injury to nerves and spinal cord	5
			Injury to blood vessels	6
			Muscles and Tendons	7
			Crushing Injury	8
			Traumatic amputation	9
			Injury to internal organs	10
			Foreign body in natural orifice	11
			Burns and corrosions	12
			Other unspecified Injurie	13
5	Type of fracture	Radio button	Open	1
			Closed	2
6	Describe the injury	Text Box
7	Injury classification as per ICD_10	Dropdown	Include only Chapter XIX up to Burns and corrosion, Certain early complications of trauma and Sequel of injuries. Cascade based on response from Q2 and Q5
8	How is the severity of injury	Dropdown	Minor	1
			Moderate	2
			Serious	3
			Severe	4
			Critical	5
			Maximum (Untreatable)	6
9	Abbreviated injury Scale (AIS)	Dropdown	AIS 2008 code set. Cased based on Q2, Q4, Q6 And Q7.
10	FAST Result	Dropdown	Done-Positive	1
			Done-Negative	2
			Equivocal	3
			No Facility	994
			Not done	996
			Unknown	998
			Not recorded	999
11	What is the patient treatment status?	Dropdown	First Aid Provided	1	Yes	If 997 is selected go to Q12 else skip Q12
			Stabilized	2
			Treated in emergency room	3
			Definitive care (Comprehensive care)	4
			LAMA	5
			Others	997
12	Specify Treatment status	Text Box
13	What is the Patient admission status?		Referred	1	Yes	If 1 is selected show questions 17 to 26 or skip questions 20 to 26. If 2 is selected skip questions 20 to 26. If 3 is selected show questions 17, 18 and 19 and skip rest of the questions
			In hospital care (Shifted to IP/Remains admitted)	2
			Abscond/Left	3
14	What was the time taken to initiate treatment? (Time between admission and first aid/ stabilization/ treatment/ to declare brought dead based on options selected in Q18)	Date pick	Date format
		Time pick	Time format
15	Reason for delay in treatment?	Dropdown	Delay to get investigation results	1		If 997 is selected go to Q16 else skip Q16
			Doctors not available	2
			Delay in blood availability	3
			Others	997
			Not applicable	996
16	Specify, reason for delay in treatment	Text box
17	Outcome	Dropdown	Alive	1		If 2 is selected show Q27, show Q27, 28 and 29 and skip rest of the questions If 1 is selected Show Q18, 19 and skip rest of the questions
			Dead	2
18	Date of discharge	Calendar Format	dd/mm/yyyy
19	Discharge summary	Text Box
20	What is the centre referred?	Text	Primary health care facility	1	Yes
			District Government Hospitals	2
			Other Government Hospitals	3
			Private hospitals	4
			Private nursing home	5
			Unknown	998
21	What was mode of transport for shifting the patient to higher centre?	Dropdown	Government Ambulance	1	Yes	If 997 is selected go to Q22 else skip Q22
			Private Ambulance	2
			Private vehicle	3
			Others	997
			Unknown	998
22	Specify mode of transport for shifting patient	Text Box
23	Date of referral	Calendar Format	dd/mm/yyy		Yes
24	Time of referral	Time Format	hh:mm
25	Reason for referral	Dropdown	Not equipped for the treatment required	1	Yes	If 997 is selected go to Q26 else skip Q26
			Specialist doctors not available	2
			Bed not available	3
			Patient’s desire	4
			Others	997
			Unknown	998
26	Specify reason for referral	Text Box
27	Date of death	Calendar Format	dd/mm/yyyy		Yes
28	Time of death	Time format	Hh:mm		Yes
29	Cause of death	Text Box