Investor Presentaiton
Colorado Violent Death Reporting System - Data Abstraction Form
Colica Demme
County:
Abstractor Name:
COPHE
A
Clear Form
For questions regarding completion of this form, please contact Ethan Jamison, CoVDRS Project Coordinator, 303-692-2093, [email protected]
Victim Demographic Information
Last Name:
Sex: ✓ Transgender' Sexual Orientation
Currently in a Relationship:
Residence City:
Residence Zip:
Current Occupation:
First Name:
Middle Name:
DOB:
✓ Race:
Hispanic/Latino/Spanish Age:
Sex of Partner
Residence County:
Residence State:
Retired
Victim was homeless
Unemployed
Residence COUNTRY (if other than U.S.)
Refer to Page 4-6 of the coding manual for additional information and coding choices
Injury and Death Information
Injury Date:
Injury City:
Injury County:
Injury State:
Injury Zip:
Injury COUNTRY (if other than U.S.):
Injured at own home
Injured at work
Injured while in custody
Manner of Death:
EMS at scene
Recent release from an institution Unknown
Alcohol use suspected
Weapon Information
Primary Weapon":
2nd Weapon Causing Injury":
F
Injury Location:
Refer to Pages 7-10 of coding manual for answer choices
Autopsy and Toxicology Information
Height (in inches):
Firearm type:
Caliber:
Refer to Page 11 of the coding manual for
Weight (in pounds):.
If Female, Pregnancy Status:
For deaths involving firearms and sharp instruments only, enter the following:
Number of Wounds (bullet entry counts as 1 wound; bullet exit counts as another):
Number of bullets that hit victim:
Wound Locations (check if present): Head
Spine
Face
Thorax
Neck
Abdomen
Upper Extremity
Lower Extremity ☐
3rd Weapon Causing Injury:
Gauge:
For any death involving a firearm, enter the following:
Firearm model:
Number of non-fatally shot persons:
Firearm Make:
Firearm Owner:
Firearm stored locked
Firearm stolen
Firearm stored loaded
Firearm Access Narrative: (enter a brief summary of how the victim obtained access to the gun and whether he/she had authorized access to the gun):
Note: one shotgun blast = 1 wound
For any death where a poison is the primary weapon, enter the following:
Substance/Poison Name
Cause of
Death$
Drug Prescribed
for³:
Refer to Pages 13-17 of
ח
coding manual for more
information & answer
choices
For deaths involving any weapon type, enter the following:
Alcohol and Drug Testing (enter regardless of weapon type; tests may be from any bodily fluid, except blood alcohol concentration, BAC):
Toxicology Tested
Date Specimens Collected:
Military time/24 hour clock
☑
Time Collected:
Substance Type (if necessary, please refer
Tested Positive
to drug manual for info on substance types)
Alcohol
Carbon Monoxide (CO)
Amphetamines
☐
☐
☐
☐
.ப
Anticonvulsants
Antidepressants
୮
☐
L
☐
(Please list any additional poisons on the
back of this form)
Suspect (or "S") Information (list in order of primacy; applicable only if NOT self-inflicted) or Suspect Info Unknown
*Blood Alcohol Concentration (BAC) (mg/dl):,
Co Source
S Number
Age
(years)
Gender
Race
Hispanic
1
2
☐
☐
History of abuse of victim
by this S
☐
S was caregiver for
the victim
5 attempted 5 mentally
suicide
ill
ப
3
4
ப
☑
Π
L
L
Page 1 of 4
Antipsychotics
Barbiturates
Benzodiazepines
cocain
Marijuana
Muscle Relaxants
Opiates
(List any additional substances on back of this form)
Refer to Page 12 of coding manual for answer choices
Suspect-Victim Relationships (list all relationships that apply³):
S1 is a
S2 is a
to the Victim S3 is a
to the Victim
▾ to the Victim
S4 is a
to the Victim
*Please list any additional suspects and suspect information on the back of this form
Circumstances - Complete the following for ALL MANNERS OF DEATH
Refer to Pages 18-19 of eading manual for
answer choices
NOTE: each circumstance checked should be
explained in the narrative (see pg.4)
CDPHE
COLORADO
Center for Health
& Environmental Data
Department of Public Health & Environment
CoVDRS Data Abstraction Form -Version 2018.09
Mental Health and Substance Abuse Related:
Current depressed mood
☐
Alcohol problem
☐
Crisis
Current mental health diagnosis(es)
Other substance
☐
Crisis
☐
problem/abuse
Current mental health treatment
☐
Other addiction
Please Lid
Ever treated for mental health or
substance abuse problem
Crisis
☐
☐
Relationship Problems:
Intimate partner violence
Intimate partner problem
Crisis
Crisis
Family relationship problem
Other relationship problem
Crisis
Crisis
Page 2 of 4
ח
Crisis Variables: These
should be endorsed when
the circumstance was noted
to have occurred/or
worsened 2 weeks prior to
death
CoVDRS Data Abstraction Form - Version 2018.09
53
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