Data Collector ID (initials) __ __ __   Case No. __ __ __ __
Date Data Collected __ __ /__ __ /__ __   Hospital Code __ __
  Data Abstraction Form for UNC Pedestrian and Bicyclist Injury Study  
Case Identification        
Type of Event:
0. Unsure/Unk.
1. Pedestrian
2. Bicyclist		 Date Injured:
__ __ /__ __ /__ __
month day year		 Time Injured:
__ __ : __ __ 		Location of Injury Event:
City/Town______________
County _______________		  
         
Patient Characteristics        
Date of Birth:
__ __ /__ __ /__ __
month day year		 Gender:
0. Unknown
1. Male
2. Female		 Race:
0. Unknown
1. White
2. Black
3. Hispanic 		4. Asian
5. Amer. Indian
6. Other/Mixed 		 
Injury Event Characteristics      
         
Place Where Injury Occurred:
0. Unknown
1. On a roadway (Includes travel lanes, shoulder median, crosswalk, etc. Also includes any driveway, alley,
parking lot, etc. where it intersects a roadway.)

2. On a sidewalk or path alongside a roadway
3. On a public trail or other path not along a roadway
4. In a commercial/retail parking area (shopping mall, convenience store, gas station, etc.)
5. In a residential parking area (apartments, housing development, etc.)
6. In other parking area (public parking lot, school, park, church, etc.)
7. In a public driveway, alley, or other entrance way (Event must occur entirely off-road.)
8. At a park, playground, ballfield, or other public off-road location
9. In a private driveway or yard (Code only if event occurs entirely off-road.)
10. Other or uncertain (Please give as detailed a description as possible.) _______________ 		 
         
Motor Vehicle Involvement:
0. Unknown
1. Yes - person struck, or was struck by, a motor vehicle (either on foot or or while riding) [Code even if
hit & run]

2. No - no motor vehicle involved (fall from bicycle, ped struck by bicycle, ped tripped on curb, etc.)
3. Motor vehicle involved, but no contact made (car runs bicyclist off road, car causes ped to step back and
trip on curb, etc.)

4. Other/uncertain (please describe) ___________________ 		 
         
Alcohol Involvement:
0. Unknown / no information
1. Presumed not impaired
2. Not tested, but impairment indicated
3. Tested
Test results ___ ___ml/dl 99=N/A
Bicyclist Helmet Use:
0. Unknown or N/A
1. Helmet used
2. Helmet used, but
worn incorrectly or
improper helmet

3. No helmet used		 Equipment:
0. None (pedestrian only)
1. Bicycle
2. Child's bike - tricycle, big wheel,
pedal scooter, etc.

3. Adult tricycle
4. Wheelchair
5. Skates/rollerblades
6. Skateboard
7. Baby stroller, backpack, etc.
8. Other____________
         
Drug Involvement:
0. Unknown / no information
1. Presumed no drug use
2. Not tested, but suspected use
3. Tested positive for drugs
4. Tested negative for drugs
5. Tested, but results unknown		  
         
Injury Characteristics        
         
Location:
0. Unknown
1. Head
2. Face / neck
3. Chest
4. Back / spine
5. Abdomen / pelvis / lower back
6. Upper limb
7. Lower limb
8. Other (describe)		 Type:
0. Unknown
1. Laceration / open wound
2. Contusion (skin intact)
3. Fracture
4. Dislocation
5. Sprain / strain
6. Intracranial
7. Other internal inj.
8. Superficial injury
9. Other (describe)		  
Loc. Type        

Injury 1 ____ ____ __________________________________________________

Injury 2 ____ ____ __________________________________________________

Injury 3 ____ ____ __________________________________________________

Injury 4 ____ ____ __________________________________________________

Injury 5 ____ ____ __________________________________________________

 
         
Glascow Coma Score ___ ___ (99=Unknown) Patient Disposition:
0. Unknown
1. Treated and released
2. Admitted___________________
3. Admitted to OR
4. Admitted to ICU________________
5. Admitted to floor
6. Transferred to other facility:
7. Fatal
8. Other		  

Narrative Description of Injury Causing Event / Other Comments:		  
__________________________________________________________________________
__________________________________________________________________________		  
         
Follow-up Contact?
1. Not necessary
2. Yes - phone
3. Yes - other
4. No - no consent
5. No - phone # unk.
6. No - no response
7. No - refused
8. Other _________		  
Date Treated at ER __ __ /__ __ /__ __

Patient ID# ______________________