Appendix 1

A. Obtain information from ED study log and ED records:

1. Site:

ED ID Label / Stamp

1. ED Log #:

1. Case ID:

1. RESEARCH ASSISTANT ID:

2. ED Rec# :

3. Med Rec#:

4. Date Admitted:

5. Time Admitted:  (24 hr clock)

6. Name: (First,  Middle,  Last)
 

B. Obtain INFORMED CONSENT and then alcohol/risk information through interview:

VII. A) Hello, I am (fill in name) from emergency medicine research. I understand that you were in a traffic crash today. Our department is doing highway safety research that focuses on patients' risks of being in a traffic crash in the future. Would you mind answering a few questions about your own risk of being in a future crash? 

B) We know that the three things that most affect risk are speed, seat belts, and alcohol use. The questions I'm going to ask you will deal with these three areas. Is that okay? 

C) Would you mind if we call you at home in three months and six months from now to see how you are doing? 

C. CONTINUE INTERVIEW ONLY IF INFORMED CONSENT OBTAINED:

VIII. First of all, when you drive or ride in a car, would you say you buckle your seatbelt: all the time, most of the time, some of the time, or never? 

IX. When you're driving a car, do you insist that your passengers buckle up: all the time, most of the time, some of the time, or never? 

X. If you had to give one reason why you do not always buckle your seatbelt, what would it be? 

XI. When you drive, do you drive under the speed limit: all the time, most of the time, some of the time, or 

XII. If you had to pick one reason why you drive over the speed limit, what would it be? 

Continue interview with TWEAK

XIII. 

a) How many drinks does it take before you begin to feel the first effects of the alcohol? 

SCORE

b) Is the answer to a. three (3) drinks or more? 

SCORE

XIV. 

a) How many drinks does it take before the alcohol makes you fall asleep or pass out? OR If you ever drink until you pass out, what is the largest number of drinks you have? 

b) Is the answer to a. five (5) drinks or more? 

SCORE

XV. Have your friends or relatives worried or complained about you drinking in the past? 

SCORE

XVI. Do you sometimes take a drink in the morning when you first get up? 

SCORE

XVII. Are there times when you drink and afterwards you can't remember what you said or did? 

SCORE

XVIII. Do you sometimes feel the need to cut down on your drinking? 

SCORE

XIX. a) TOTAL SCORE: 

b) TWEAK RESULT 

D. Obtain breath alcohol information from passive sensor during interview or serum readings from ED records at a later time:

XX. BAC

a) Reading:

b) Time:(24 hr clock)

c) Source:

XXI.

a) Optional Active BAC:

b) Time: (24 hr clock)

E. Group Assignment:

F. Follow up:

1. Group:

2. Referral Agency:

3. Appointment Date:

G. Obtain patient contact information from ED records and verify with or obtain from patient:

IV. Address:

a) Current " Local Address: (City, State, Zip)

b) How long? If <5 years (Year, Month)

c) Previous Permanent Address: (City, State, Zip)

d) How long? (Year, Month)

V. Phones:

a) Home:

b) Phone 2:

c) Name:

d) Relation:

VI. Living Status:

VII. Support at ED:

H. Obtain and/or verify basic motor vehicle crash information with patient:

VIII. Driver License #:

IX. Driver License State:

X. Date:

XI. Time: (24 hr clock)

XII. State:

XIII. County:

XIV. City:
a) 

b) 

XV. Location:

I. Obtain additional patient identification information from ED records:

XVI. Social Security #:

XVII. Date of Birth:

XVIII. Sex:

XIX. Race:

J. Additional ED and Injury information from ED records:

XX. Arrive ED Via:

XXI. Leave ED to:

XXII. E Code:

N Codes:

XXIV. Trauma Score:

XXV. AIS:

K. Additional motor vehicle crash information from investigating officer and/or report:

XXVI. Agency Investigated by: 

XXVII. Victim Type:

XXVIII. Violation (if not passenger):

a) Violation 1

b) Violation 2

c) Violation 3

Violation codes (Circumstances contributing to the collision)

XXIX. Arrests:

a) 

b) Charge(s)