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The value entered is not a valid Vanderbilt Medical Record Number (i.e. 4- to 9-digit number, excluding leading zeros). Please try again.

The value you provided must be within the suggested range

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The value entered must be a time value in the following format HH:MM within the range 00:00-23:59 (e.g., 04:32 or 23:19).

This field must be a 5 or 9 digit U.S. ZIP Code (like 94043). Please re-enter it now.

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Required format:

EqyZIioWwXMW43NYhpDbzmNYSZCI234gZXV68mrqqY8sp6efGxoDHP79YyafmvyI9XzpNsrCf9aS598Hq7BCSZp

Rhode Island Opioid Overdose Case Report

Please complete the survey below.

The State of Rhode Island recently changed hospital’s reporting requirements for opioid overdose-related emergency department visits Opioid Overdose Prevention and Reporting (216-RICR-20-20-5). The changes to regulation require hospitals to provide additional information from patients who have experienced an opioid related overdose including first name, last name and date of birth. To increase the security of the information collected, the Rhode Island Department of Health switched to this survey platform (REDCap). The previous survey platform (WUFOO) is no longer active, please use this survey going forward.

Thank you!

Date Created

Patient First Name

* must provide value

Patient Last Name

* must provide value

Patient Date of Birth

* must provide value

M-D-Y

Patient Medical Record Number

* must provide value

Patient City or Town of Residence

* must provide value

In What City or Town did the Overdose Occur?

* must provide value

Patient Sex as Assigned at Birth

* must provide value

Male

Female

Prefer not to answer

Other

Not asked

Unknown

reset

Patient Gender Identity (Self Reported)

* must provide value

Man

Woman

Trans man

Trans woman

Gender non-conforming/non-binary

Patent prefers not to answer

Other

Not asked

reset

If Other, Please Specify Patient Gender Identity

* must provide value

If Other, Please Specify Sex Assigned at Birth

* must provide value

Patient Sexual Orientation (Self Reported)

* must provide value

Straight or heterosexual

Lesbian, gay

Queer

Bisexual

Asexual

Patient doesn't know

Patient prefers not to answer

Other

Question not asked by organization

reset

If Other, Specify Patient Sexual Orientation

* must provide value

Patient Race (Self Reported)

* must provide value

White

Black/African American

Native American

Asian

Other

Unknown

reset

Patient Ethnicity (Self Reported)

* must provide value

Hispanic

Non-Hispanic

Unknown

reset

Emergency Department Admission Date

* must provide value

M-D-Y

Primary ICD 10 Code

* must provide value

Was Toxicology Positive for Fentanyl?

* must provide value

Yes

Not tested

Toxicology results pending

Unknown

reset

Patient Outcome

* must provide value

Where was the Patient Transferred?

Was Naloxone Administered Prior to Arrival at the Emergency Department?

* must provide value

Yes No Unknown

reset

If yes, by Whom?

* must provide value

EMS

Police

Family/friend/layperson

Other

Unknown

Total Naloxone Administered Prior to Emergency Department Arrival

* must provide value

Was Naloxone Administered at the Emergency Department?

* must provide value

Yes No Unknown

reset

Total Naloxone Administered at the Emergency Department

* must provide value

Was On Site Counseling Provided?

* must provide value

Treatment

* must provide value

Patient received a referral to a Center of Excellence in Medication Assisted Treatment

Referral to substance abuse treatment and/or recovery services

Patient entered detox

Initiation of medication to treat opioid use disorder in the ED

Not offered

The patient refused

Patient still receiving treatment

Unknown

Did the Patient Receive Naloxone at Discharge?

* must provide value

How did the Patient Arrive at the Hospital?

* must provide value

If Other, Please Specify How the Patient Arrived at the Hospital

* must provide value

Hospital Name

* must provide value

If Other or Non Hospital Please Include Name of Facility

* must provide value

Who Should RIDOH Contact from Your Organization if we Have a Question About this Data Entry?

* must provide value

Organization Contact's Email Address

* must provide value

Optional Comments

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