Registry Number
Hospital Codes
Medical Record Number
Patient SSN
Patient Name
Date of Birth (MMDDYY)
Patient City
Patient County
Patient State
Patient Zip Code
If a Transfer Patient:
   Hospital Transferred From
   City of Hospital Location
   Date of Arrival
   Time of Arrival
Parent or Guardian
Parent/Guardian SSN
Date of Injury (MMDDYY)
Time of Injury

Time CAT Scan
Time X-ray
Time Trauma Surgeon Arrived
Time Orthopedic Surgeon Arrived
Time Neurosurgeon Arrived
Time Discharge From Emergency Department
Emergency Department Disposition
Receiving Hospital Name
Date Arrive Operating Room
Time Arrive Operating Room
Procedures 1-5
Diagnoses 1-5
Admission Date
Discharge Date
ICU Days
Injury City
Injury County
Injury State
Place of Injury
Contributing Factor
Injury Work Related
Arrive by Transport Type
Ambulance Service Number
Ambulance Report Number
Ambulance Times
   Unit Dispatched
   Arrive Location
   Depart Location
   Arrive Destination
Transfer Hospital
Date Arrive Emergency Department
   Time Arrive Emergency Department
   Glasgow Coma Score
   Cardiopulmonary Functions
   Time Intubated Emergency

Degree Disability
Source of Payment
Abbreviated Injury Scale
Injury Severity Score
Degree of Disability at Discharge for:
   Feeding Self (1990-Present)
   Expressing Self (1990-Present)
   Locomotion (1990-Present)
File Identifier (HSCI or Trauma) (1990-Present)
Blood Alcohol Concentration (1990-Present)
Billed Hospital Charges (1990-Present)
Number of Records per Person per Incident