Stroke Program Data Submission Form

Date(Required)

Site(Required)

Submitted by:(Required)

Email(Required)

Reporting Month(Required)

How many total Acute ISCHEMIC Stroke (AIS) patients were seen in your facility?(Required)

Do not include patients with a final diagnosis of TIA or hemorrhagic stroke when submitting data–we are ONLY looking at ISCHEMIC strokes. If your site has in-house neurology, still include the total number of ISCHEMIC stroke patients seen at your facility.

How many acute ISCHEMIC stroke (AIS) patients seen in your facility DID NOT receive an IDHI Stroke Program telestroke consult? Include those seen by in-house neurology during Code Stroke or other telestroke consult services.(Required)

Reminder: This number should match the number calculated below in “Total Number of Patients IDHI Stroke Program DID NOT consult for”

Reasons IDHI Stroke Program was not contacted for AIS Patients Within Your Facility Only: (Choose only one category per patient)

If a patient meets more than one exclusion criteria (i.e. arrived outside the 4.5 hour window and used anticoagulants within the last 48 hours select the first exclusion criteria when going down the list–for this example you would count the patient as “symptoms >4.5 hours”)

Number of patients with symptoms > 4.5 hours:(Required)

Number of patients who used newer anticoagulants (Xarelto, Pradaxa, Eliquis) in the last 48 hours:(Required)

Number of patients with a prior medical history of intracranial hemorrhage:(Required)

This is a PREVIOUS intracranial hemorrhage, not an acute hemorrhagic stroke.

Number of patients presenting with abnormal labs:(Required)

Number of patients with either an intracranial neoplasm, AVM, or untreated aneurysm > 10mm:(Required)

Number of patients showing minor deficits/symptoms resolved:(Required)

Number of patients IDHI Stroke Program DID NOT consult with for any other reason not listed above:

Include those seen by in-house neurology or other telemedicine service here, there will be a pop-up box that will allow you to input that number once this box is completed.

Number of AIS patients that received an in-house neurology consultation

Please specify other reasons not listed above:(Required)

Total Number of Patients IDHI Stroke Program DID NOT consult for:(Required)

Note: This number should match the number above for those AIS patients in your facility who DID NOT receive an IDHI Stroke Program telestroke consult.

Stroke Survivor(s):

Note: Stroke Survivors appear in annual reports and at conferences.

Please check the box below if any of your patients could be considered a Stroke Program Stroke Survivor?

Possible Stroke Survivor

Note:We will contact you for more information if the box is checked.

Community Education

Active Events

Active Event Name(Required)

Event Location(Required)

**Reminder-social media/online active events MUST be accompanied by a face-to-face active event.

Address(Required)

ZIP / Postal Code

Education Method(Required)

Activity Engagement Level(Required)

About how many people were educated face to face?(Required)

Another Active Event?

Yes

Active Event Name

Event Location

Address(Required)

ZIP / Postal Code

Education Method

Activity Engagement Level

About how many people were educated face to face?(Required)

Is there a 3rd Active Event?

Yes

Active Event Name

Event Location

Address(Required)

ZIP / Postal Code

Education Method

Activity Engagement Level

About how many people were educated face to face?

Is there a 4th Active Event?

Yes

Active Event Name

Event Location

Address(Required)

ZIP / Postal Code

Education Method

Activity Engagement Level

About how many people were educated face to face?(Required)

Is there a 5th Active Event?

Yes

Active Event Name

Event Location

Address(Required)

ZIP / Postal Code

Education Method

Activity Engagement Level

About how many people were educated face to face?

Is there a 6th Active Event?

Yes

Active Event Name

Event Location

Address(Required)

ZIP / Postal Code

Education Method

Activity Engagement Level

About how many people were educated face to face?

Is there a 7th Active Event?

Yes

Active Event Name

Event Location

Address(Required)

ZIP / Postal Code

Education Method

Activity Engagement Level

About how many people were educated face to face?

Is there an 8th Active Event?

Yes

Active Event Name

Event Location

Address(Required)

ZIP / Postal Code

Education Method

Activity Engagement Level

About how many people were educated face to face?

Is there a 9th Active Event?

Yes

Active Event Name

Event Location

Address(Required)

ZIP / Postal Code

Education Method

Activity Engagement Level

About how many people were educated face to face?(Required)

Is there a 10th Active Event?

Yes

Active Event Name

Event Location

Address(Required)

ZIP / Postal Code

Education Method

Activity Engagement Level

About how many people were educated face to face?(Required)

Community Education

Passive Events

Passive Event Name(Required)

Event Location

Address(Required)

ZIP / Postal Code

Education Method

Number of Participants Reached:(Required)

Another Passive Event?

Yes

Passive Event Name

Event Location

Address(Required)

ZIP / Postal Code

Education Method

Number of Participants Reached:

Is there a 3rd Passive Event?

Yes

Passive Event Name

Event Location

Address(Required)

ZIP / Postal Code

Education Method

Number of Participants Reached:

Is there a 4th Passive Event?

Yes

Passive Event Name

Event Location

Address(Required)

ZIP / Postal Code

Education Method

Number of Participants Reached:

Is there a 5th Passive Event?

Yes

Passive Event Name

Event Location

Address(Required)

ZIP / Postal Code

Education Method

Number of Participants Reached:

Is there a 6th Passive Event?

Yes

Passive Event Name

Event Location

Address(Required)

ZIP / Postal Code

Education Method

Number of Participants Reached:

Is there a 7th Passive Event?

Yes

Passive Event Name

Event Location

Address(Required)

ZIP / Postal Code

Education Method

Number of Participants Reached:

Is there an 8th Passive Event?

Yes

Passive Event Name

Event Location

Address(Required)

ZIP / Postal Code

Education Method

Number of Participants Reached:

Is there a 9th Passive Event?

Yes

Passive Event Name

Event Location

Address(Required)

ZIP / Postal Code

Education Method

Number of Participants Reached:

Is there a 10th Passive Event?

Yes

Passive Event Name

Event Location

Address(Required)

ZIP / Postal Code

Number of Participants Reached:

Education Method

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