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* 1. The following pages require reporting of stroke data in your Trauma Service Area.
Person entering stroke data

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* 2. Email address of person entering date

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* 3. Phone # of person entering data

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* 4. Your professional title:

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* 5. Hospital represented by person entering data

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* 6. County of Hospital

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* 7. Urban or Rural

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* 8.  “Total number of stroke cases.”

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* 9.  Number of Ischemic Strokes

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* 10.  Number of Intracerebral Hemorrhages

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* 11. Number of Subarachnoid Hemorrhages

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* 12. Number of Transient Ischemic Attack (<24 hours) (TIA)

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* 13.  Number of stroke not otherwise specified

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* 14. Number arriving via EMS from home/scene

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* 15.  Number arriving via private transport/taxi/other from home/scene

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* 16. Number arriving via transfer from other hospital

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* 17. Number with arrival mode not documented or unknown

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* 18. “Of the ischemic stroke cases reported in Item 9, how many had an NIH stroke scale performed?”

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* 19. “ Of the ischemic stroke cases reported in Item 9, how may received tPA therapy?”

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* 20. “Of all the cases reported in Item 9, how many received tPA within 60 minutes or less from the time of arrival?”

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* 21. “Of the ischemic stroke cases reported in Item 9, how many had health insurance.”

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* 22. “Of the ischemic stroke cases reported in Item 9, how many did not have health insurance.”

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* 23. Of the ischemic stroke cases reported in Item 9, with health insurance not documented or unknown

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* 24. “Of the ischemic stroke cases reported in Item 9, how many received endovascular therapy?”

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* 25.  “Of the endovascular therapy cases reported in Item 9, how many received endovascular therapy within 60 minutes?”

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* 26. Number of ischemic stroke cases discharged to home

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* 27. Number of ischemic stroke cases discharged to inpatient rehabilitation

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* 28. Number of ischemic stroke cases discharged to skilled nursing facility

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* 29. Number of ischemic stroke cases discharged to hospice care (home hospice or facility hospice)

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* 30. Number of ischemic stroke cases transferred to higher level of care

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* 31. Number of ischemic stroke cases expired

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* 32. Number of ischemic stroke cases discharged to “other” or not known/reported

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