ADH Data Request Form

Please complete the request form below. When selecting variables, only select variables that are required for the project. Please consult the relevant data dictionary for details about the variables.

Thank you!

Title of Project

* must provide value

Date of request

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M-D-Y

Primary Requestor/Investigator Name

* must provide value

Primary Requestor's Title

* must provide value

Secondary Requestor/Investigator Name

Secondary Requestor's Title

Requesting Agency

* must provide value

Primary contact phone number

Primary contact address

Primary contact email

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Dataset name

Vital Statistics - Birth

Vital Statistics - Death

Hospital Discharge Data - Inpatient

Hospital Discharge Data - Emergency Department

Arkansas Trauma Registry

Arkansas Cancer Registry

Behavioral Risk Factor Surveillance System (BRFSS)

Pregnancy Risk Assessment Monitoring System (PRAMS)

HIV/STI/Hepatitis C/TB Surveillance dataset

Prescription Drug Monitoring Program

COVID-19 Registry

Immunization Registry (WebIZ)

Other dataset(s)

Please check the dataset(s) from the list above. Once a dataset is checked, a list of variables available from that dataset will be shown below. Select the specific variables that are being requested from each dataset. PLEASE NOTE: If a dataset is unchecked from the list above after selecting variables from that dataset, the previously selected variables will clear and will need to be selected again

Vital Statistics - Birth

U.S. Territory or Canadian Province of Birth (Father) - literal

Time of Birth

Sex

Date of Birth (Infant)--Month

Date of Birth (Infant)--Day

County of Birth

Place Where Birth Occurred (type of place or institution)

Birthplace of Mother--Country

Residence of Mother--City

Residence of Mother--County

Residence of Mother--Country

Residence of Mother--Inside City Limits

Mother Married?--Ever

Mother Married?-- At Conception, at Birth or any Time in Between

Mother Married?--Acknowledgement of Paternity Signed

Mother's Education

Mother's Education--Edit Flag

Mother of Hispanic Origin?--Mexican

Mother of Hispanic Origin?--Puerto Rican

Mother of Hispanic Origin?--Cuban

Mother of Hispanic Origin?--Other

Mother of Hispanic Origin?--Other Literal

Mother's Race--White

Mother's Race--Black or African American

Mother's Race--American Indian or Alaska Native

Mother's Race--Asian Indian

Mother's Race--Chinese

Mother's Race--Filipino

Mother's Race--Japanese

Mother's Race--Korean

Mother's Race--Vietnamese

Mother's Race--Other Asian

Mother's Race--Native Hawaiian

Mother's Race--Guamanian or Chamorro

Mother's Race--Samoan

Mother's Race--Other Pacific Islander

Mother's Race--Other

Mother's Race--First American Indian or Alaska Native Literal

Mother's Race--Second American Indian or Alaska Native Literal

Mother's Race--First Other Asian Literal

Mother's Race--Second Other Asian Literal

Mother's Race--First Other Pacific Islander Literal

Mother's Race--Second Other Pacific Islander Literal

Mother's Race--First Other Literal

Mother's Race--Second Other Literal

Mother's Race Tabulation Variable 1E

Mother's Race Tabulation Variable 2E

Mother's Race Tabulation Variable 3E

Mother's Race Tabulation Variable 4E

Mother's Race Tabulation Variable 5E

Mother's Race Tabulation Variable 6E

Mother's Race Tabulation Variable 7E

Mother's Race Tabulation Variable 8E

Mother's Race Tabulation Variable 16C

Mother's Race Tabulation Variable 17C

Mother's Race Tabulation Variable 18C

Mother's Race Tabulation Variable 19C

Mother's Race Tabulation Variable 20C

Mother's Race Tabulation Variable 21C

Mother's Race Tabulation Variable 22C

Mother's Race Tabulation Variable 23C

Father's Education

Father's Education--Edit Flag

Father of Hispanic Origin?--Mexican

Father of Hispanic Origin?--Puerto Rican

Father of Hispanic Origin?--Cuban

Father of Hispanic Origin?--Other

Father of Hispanic Origin?--Other Literal

Father's Race--White

Father's Race--Black or African American

Father's Race--American Indian or Alaska Native

Father's Race--Asian Indian

Father's Race--Chinese

Father's Race--Filipino

Father's Race--Japanese

Father's Race--Korean

Father's Race--Vietnamese

Father's Race--Other Asian

Father's Race--Native Hawaiian

Father's Race--Guamanian or Chamorro

Father's Race--Samoan

Father's Race--Other Pacific Islander

Father's Race--Other

Father's Race--First American Indian or Alaska Native Literal

Father's Race--Second American Indian or Alaska Native Literal

Father's Race--First Other Asian Literal

Father's Race--Second Other Asian Literal

Father's Race--First Other Pacific Islander Literal

Father's Race--Second Other Pacific Islander Literal

Father's Race--First Other Literal

Father's Race--Second Other Literal

Father's Race Tabulation Variable 1E

Father's Race Tabulation Variable 2E

Father's Race Tabulation Variable 3E

Father's Race Tabulation Variable 4E

Father's Race Tabulation Variable 5E

Father's Race Tabulation Variable 6E

Father's Race Tabulation Variable 7E

Father's Race Tabulation Variable 8E

Father's Race Tabulation Variable 16C

Father's Race Tabulation Variable 17C

Father's Race Tabulation Variable 18C

Father's Race Tabulation Variable 19C

Father's Race Tabulation Variable 20C

Father's Race Tabulation Variable 21C

Father's Race Tabulation Variable 22C

Father's Race Tabulation Variable 23C

Mother Transferred?

Date of First Prenatal Care Visit--Month

Date of First Prenatal Care Visit--Day

Date of First Prenatal Care Visit--Year

Date of Last Prenatal Care Visit--Month

Date of Last Prenatal Care Visit--Day

Date of Last Prenatal Care Visit--Year

Total Number of Prenatal Care Visits

Total Number of Prenatal Care Visits--Edit Flag

Mother's Height--Feet

Mother's Height--Inches

Mother's Height--Edit Flag

Mother's Prepregnancy Weight (in whole pounds)

Mother's Prepregnancy Weight--Edit Flag

Mother's Weight at Delivery (in whole pounds)

Mother's Weight at Delivery--Edit Flag

Did Mother get WIC Food for Herself?

Previous Live Births Now Living

Previous Live Births Now Dead

Previous Other Pregnancy Outcomes

Date of Last Live Birth--Month

Date of Last Live Birth--Year

Date of Last Other Pregnancy Outcome--Month

Date of Last Other Pregnancy Outcome--Year

Number of Cigarettes Smoked in 3 months prior to Pregnancy

Number of Cigarettes Smoked in 1st 3 months

Number of Cigarettes Smoked in 2nd 3 months

Number of Cigarettes Smoked in third or last trimester

Principal source of Payment for this delivery

Date Last Normal Menses Began--Year

Date Last Normal Menses Began--Month

Date Last Normal Menses Began--Day

Risk Factors--Prepregnancy Diabetes

Risk Factors--Gestational Diabetes

Risk Factors--Prepregnancy Hypertension

Risk Factors--Gestational Hypertension

Risk Factors--Previous Preterm Births

Risk Factors--Poor Pregnancy Outcomes

Risk Factors--Vaginal Bleeding (NCHS DELETED THIS ITEM EFFECTIVE 2011)

Risk Factors--Infertility Treatment

Risk Factors--Previous Cesarean

Risk Factors--Number Previous Cesareans

Risk Factors--Number Previous Cesareans--Edit Flag

Infections Present--Gonorrhea

Infections Present--Syphilis

Infections Present--Herpes Simplex (HSV) (NCHS DELETED THIS ITEM EFFECTIVE 2011)

Infections Present--Chlamydia

Infections Present--Hepatitis B

Infections Present--Hepatitis C

Obstetric Procedures--Cervical Cerclage

Obstetric Procedures--Tocolysis

Obstetric Procedures--Successful External Cephalic Version

Obstetric Procedures--Failed External Cephalic Version

Onset of Labor--Premature Rupture of Membranes

Onset of Labor--Precipitous Labor

Onset of Labor--Prolonged Labor

Characteristics of Labor & Delivery--Induction of Labor

Characteristics of Labor & Delivery--Augmentation of Labor

Characteristics of Labor & Delivery--Non-vertex Presentation (NCHS DELETED THIS ITEM EFFECTIVE 2011)

Characteristics of Labor & Delivery--Steroids

Characteristics of Labor & Delivery--Antibiotics

Characteristics of Labor & Delivery--Chorioamnionitis

Characteristics of Labor & Delivery--Meconium Staining

Characteristics of Labor & Delivery--Fetal Intolerance

Characteristics of Labor & Delivery--Anesthesia

Method of Delivery--Attempted Forceps (NCHS DELETED THIS ITEM EFFECTIVE 2011)

Method of Delivery--Attempted Vacuum (NCHS DELETED THIS ITEM EFFECTIVE 2011)

Method of Delivery--Fetal Presentation

Method of Delivery--Route and Method of Delivery

Method of Delivery--Trial of Labor Attempted

Maternal Morbidity--Maternal Transfusion

Maternal Morbidity--Perineal Laceration

Maternal Morbidity--Ruptured Uterus

Maternal Morbidity--Unplanned Hysterectomy

Maternal Morbidity--Admit to Intensive Care

Maternal Morbidity--Unplanned Operation

Birthweight in grams

Birthweight--Edit Flag

Obstetric Estimation of Gestation

Obstetric Estimation of Gestation--Edit Flag

Apgar Score at 5 Minutes

Apgar Score at 10 Minutes

Plurality

Set Order

Number of Live Born

Matching Number

Plurality--Edit Flag

Abnormal Conditions of the Newborn--Assisted Ventilation

Abnormal Conditions of the Newborn--Assisted Ventilation > 6 hours

Abnormal Conditions of the Newborn--Admission to NICU

Abnormal Conditions of the Newborn--Surfactant Replacement

Abnormal Conditions of the Newborn--Antibiotics

Abnormal Conditions of the Newborn--Seizures

Abnormal Conditions of the Newborn--Birth Injury

Congenital Anomalies of the Newborn--Anencephaly

Congenital Anomalies of the Newborn--Meningomyelocele/Spina Bifida

Congenital Anomalies of the Newborn--Cyanotic congenital heart disease

Congenital Anomalies of the Newborn--Congenital diaphragmatic hernia

Congenital Anomalies of the Newborn--Omphalocele

Congenital Anomalies of the Newborn--Gastroschisis

Congenital Anomalies of the Newborn--Limb Reduction Defect

Congenital Anomalies of the Newborn--Cleft Lip with or without Cleft Palate

Congenital Anomalies of the Newborn--Cleft Palate Alone

Congenital Anomalies of the Newborn--Down Syndrome

Congenital Anomalies of the Newborn--Suspected Chromosomal disorder

Congenital Anomalies of the Newborn--Hypospadias

Was Infant Transferred Within 24 Hours of Delivery?

Is Infant Living at Time of Report?

Is Infant Being Breastfed? (RECOMMENDED CHANGE TO "AT DISCHARGE" EFFECTIVE 2004)

NCHS USE ONLY: Receipt date -- Year

NCHS USE ONLY: Receipt date -- Month

NCHS USE ONLY: Receipt date -- Day

Mother's Reported Age

Father's Reported Age

Risk Factors--Hypertension Eclampsia (RECOMMENDED ADDITION EFFECTIVE 2004)

Risk Factors--Infertility: Fertility Enhancing Drugs (RECOMMENDED ADDITION EFFECTIVE 2004)

Risk Factors--Infertility: Asst. Rep. Technology (RECOMMENDED ADDITION EFFECTIVE 2004)

Date of Registration--Year

Date of Registration--Month

Date of Registration--Day

County of Birth (Literal)

City/town/place of birth (Literal)

Mother's Residence First 3 Zip Code

Mother's Residence County (Literal)

Mother's Residence Country (Literal)

Mother's Age (Calculated)

Father's Age (Calculated)

Industry of Mother

Industry of Mother (coded)

Industry of Father

Industry of Father (coded)

Father's Country of Birth (Code)

Mother's Hispanic Code for Literal

Mother's Edited Hispanic Origin Code

Mother's Bridged Race - NCHS Code

Father's Hispanic Code for Literal

Father's Edited Hispanic Origin Code

Father's Bridged Race - NCHS Code

Mother's Hispanic Origin - Specify

Mother's Race - Specify

Father's Hispanic Origin - Specify

Father's Race - Specify

Facility Mother Moved From (if transferred)

Facility Infant Transferred To (if transferred w/in 24 hours)

Attendant ("Other" specified text)

Mother's Country of Birth (Literal)

Father's Country of Birth (Literal)

Mother's Mailing Address First 3 numbers of Zip Code

Mother's Mailing Address County (Literal)

Mother's Mailing Address City/Town (Literal)

Mother's Mailing Address State (Literal)

Mother's Mailing Address Country (Literal)

SSA/EAB Citizenship Code

SSA/EAB Multiple Birth Code

SSA/EAB Feedback Release

Attendant's NPI

Certifier's NPI

Certifier Title

Certifier ("Other" specified text)

Date Signed by Certifier--Year

Date Signed by Certifier--Month

Date Signed by Certifier--Day

Date Filed by Registrar--Year

Date Filed by Registrar--Month

Date Filed by Registrar--Day

types of relationships.

Congenital Anomalies of the Newborn--Microcephaly

Foundling

PA Upon Marriage Flag

Refuses to give husband's information

Refuses to give father's information

Mother mail state FIPS code

Planned to deliver at home?

Country

State

First 3 numbers of Zip code

Country of Birth FIPS Code

State of Birth FIPS Code (Required)

Mother City Of Residence City FIPS Code

Other title

Certifier is attendant

Verification of height (Mother)

Verification of pre-pregnancy weight

Did mother smoke three months before or during pregnancy?

Prenatal care?

Verification of number of prenatal care visits

Obstetric procedures - none selected

Medical risk factors - none selected

Infection present - none selected

Maternal morbidity - none selected

Characteristics of labor - none selected

Mother transferred in for delivery?

Verification required

Other source (specify)

Onset of labor - none selected

Weight units

Pounds

Ounces

Plurality

Verification of plurality

Birth order

Infant abnormal conditions - none selected

Hydrocephalus

Bilateral renal agenesis

Down syndrome

Suspected chromosomal disorder

Down syndrome, Karyotype confirmed

Suspected chromosomal disorder, Karyotype confirmed

Down syndrome, Karyotype pending

Suspected chromosomal disorder, Karyotype pending

Congenital anomalies - none selected

Deceased Flag

Record entry date

Date received by registrar

Date of last change

Exceptions exist

Vital Statistics - Death

Multiple Cause Codes with Position Codes

Was an Autopsy performed (Y/N)

Are Autopsy findings available (Y/N)

Race = American Indian or Alaskan Native

Race = American Indian Literal

Race = Asian Indian

Race = Black

Race = Chinese

Cuban (T or F)

Hispanic Code for Literal

NCHS Hispanic

Race = Filipino

Race = Guamanian or Chamorro

Unknown Hispanic

Activity at Death

Race = Japanese

Race = Korean

Manual Underlying Cause

Multiple Cause Codes

Method DC Filed

Mexican (T or F)

Race = Native Hawaiian

Race = Other Asian

Race = Other Asian Literal

Other Hispanic (T or F)

Other Hispanic Literal

Race = Other Pacific Islander

Race = Other Pacific Islander Literal

Race = Other

Race = Other Race Literal

Place of Injury

Pronoucer Title

Puerto Rican (T or F)

Race = Other American Indian cont.

Race = Other Asian Literal cont.

Race = Other Pacific Islander cont.

Race = Other Race cont.

NCHS Race: American Indian Literal

NCHS Race: American Indian Literal cont.

NCHS Race: Other Asian Literal

NCHS Race: Other Asian Literal cont.

NCHS Race: White

NCHS Race: Other Pacific Islander Literal

NCHS Race: Other Pacific Islander Literal cont.

NCHS Race: Other Literal

NCHS Race: Other Literal cont.

NCHS Race: Black

NCHS Race: American Indian

NCHS Race: Asian Indian

NCHS Race: Chinese

NCHS Race: Filipino

NCHS Race: Japanese

NCHS Race: Korean

NCHS RACE

Unknown Race

Race = Samoan

Time of Injury

Transax Conversion Flag

Race = Vietnamese

Race = White

Age at Death

Did Injury occur at work

Was an Autopsy performed (Code)

Birth City Code

Birth City Name

Birth Country Code

Birth Country Name

Birth Date

Birth State Code

Birth State Name

Cause of Death

Date Certified

Certifier's Title

Computed Age in Years

City of Death

Country of Death Code

County of Death Code

County of Death Name

Date of Death

City of Disposition Code

City of Disposition Name

Place of Disposition

State of Disposition Code

State of Disposition Name

Residence City Code

Residence City Name

Residence Country Code

Residence Country Name

Residence County Code

Residence County Name

Residence Inside City

Residence State Code

Residence State Name

Residence First 3 numbers of ZipCode

Gender

State of Death Code

State of Death Name

Location of Death

Time of Death

Occurrence First 3 numbers of ZipCode

Decedent Education

Date Keyed into System

Autopsy Findings Available (Code)

COD Part a

COD Part a interval

COD Part b

COD Part b interval

COD Part c

COD Part c interval

COD Part d

COD Part d interval

COD Part

Type of Industry

Informant Relationship

Date Injury Occurred

Description of How Injury Occurred

Manner of Death

Marital Status

Method of Disposition

ME/Coroner Contacted

NonHispanic (T or F)

Occupation of Decedent

Pregnancy Edit Flag

Pregnant at Death

Date Pronounced Dead

Time Pronounced Dead

Registration Date

Did Tobacco Use Contrbute to Death

Age at Death Units

Update Status

Veteran Status

BRFSS variables

State FIPS Code

Geographic Stratum Code

Household Density Stratum Code

Pre-Call Status Code

Secondary Screening Flags

Interview Date

Interview Month

Interview Day

Interview Year

Final Disposition

Do you live in college housing?

Resident of State

Are you 18 years of age or older?

Number of Adults in Household

Number of Adult men in Household

Number of Adult women in Household

Is this a cellular telephone?

Do you live in a private residence?

In what state do you live?

Do you also have a landline telephone?

General Health

Number of Days Physical Health Not Good

Number of Days Mental Health Not Good

Poor Physical or Mental Health

Have any health care coverage

Multiple Health Care Professionals

Could Not See Doctor Because of Cost

Length of time since last routine checkup

Exercise in Past 30 Days

How Much Time Do You Sleep

Ever Diagnosed with Heart Attack

Ever Diagnosed with Angina or Coronary Heart Disease

Ever Diagnosed with a Stroke

Ever Told Had Asthma

Still Have Asthma

Ever told) you had skin cancer?

Ever told) you had any other types of cancer?

Ever told) you have chronic obstructive pulmonary disease, emphysema or chronic bronchitis?

Told Have Arthritis

Ever told you had a depressive disorder

Ever told) you have kidney disease?

Ever told) you have diabetes

Age When Told Diabetic

Last Visited Dentist or Dental Clinic

Number of Permanent Teeth Removed

Respondents Sex

Reported Age in Years

Latino/a, or Spanish origin?

Multiple Race

Respondent Race Choice

Marital Status

Education Level

Own or Rent Home

First 3 numbers of Zipcode of residence

County Code

Household Telephones

Do you have a cell phone for personal use?

Are You A Veteran

Employment Status

Number of Children in Household

Income Level

Internet use in the past 30 days?

Reported Weight in Pounds

Reported Height in Feet and Inches

Pregnancy Status

Are you deaf or do you have serious difficulty hearing?

Blind or Difficulty seeing

Difficulty Concentrating or Remembering

Difficulty Walking or Climbing Stairs

Difficulty Dressing or Bathing

Difficulty Doing Errands Alone

Smoked at Least 100 Cigarettes

Frequency of Days Now Smoking

Stopped Smoking in past 12 months

Interval Since Last Smoked

Use of Smokeless Tobacco Products

Ever used an e-cigarette?

Do you now use e-cigarettes, every day, some days, or not at all?

Days in past 30 had alcoholic beverage

Avg alcoholic drinks per day in past 30

Binge Drinking

Most drinks on single occasion past 30 days

Adult flu shot/spray past 12 mos

When did you (adult) receive your most recent seasonal flu shot/spray?

Pneumonia shot ever

Received Tetanus Shot Since 2005?

Had Fall Past Twelve Months

Injured in Fall

How often use seatbelts in car?

Did you drive after having too much to drink in the past 30 days?

Have You Ever Had a Mammogram

How Long since Last Mammogram

Ever Had a Pap Test

How Long Since Last Pap Test

Have you ever had an HPV test?

How long since your last HPV test?

Had Hysterectomy

Has a health professional EVER talked with you about the advantages of the PSA test?

Has a health professional EVER talked with you about the disadvantages of the PSA test?

Has a doctor EVER recommended that you have a PSA test?

Ever Had PSA Test

Time Since Last PSA Test

What was the MAIN reason you had this PSA test?

Ever Had Blood Stool Test Using Home Kit

Time Since Last Blood Stool Test

Ever Had Sigmoidoscopy/Colonoscopy

Was your last test a sigmoidoscopy or colonoscopy?

Time Since Last Sigmoidoscopy/Colonoscopy

Ever tested HIV

Month and Year of Last HIV Test

Do Any High Risk Situations Apply

Had a test for high blood sugar or diabetes in the past three years?

Ever been told by a doctor or other health professional that you have pre-diabetes or borderline diabetes?

Now Taking Insulin

How Often Check Blood for Glucose

How Often Check Feet for Sores or Irritations

Times Seen Health Professional for Diabetes

Times Checked for Glycosylated Hemoglobin

Times Feet Check for Sores/irritations

Last Eye Exam Where Pupils Were Dilated

Ever Told Diabetes Has Affected Eyes

Ever Taken Class in Managing Diabetes

How many days hard to do usual activities in past 30 days

How many days depressed in past 30 days

How many days felt anxious in past 30 days

How many days full of energy in past 30 days

Do you have Medicare?

Primary Health Insurance Coverage

Delayed Getting Medical Care

Delayed Getting Medical Care Other Response

Without Health Care Coverage Past 12 Months

Time Since Last Had Health Care Coverage

Doctor Visits Past 12 Months

Could Not Get Medicine Due To Cost

Satisfied With Care Received

Currently Have Health Care Bills

How difficult is it for you to get advice or information about health or medical topics if you need it?

How difficult is it for you to understand information that doctors, nurses and other health professionals tell you?

How difficult is it for you to understand written health information?

Provided regular care for family or friend

Relationship Of Person To Whom You Are Giving Care?

How Long Provided Care For Person.

How Many Hours Do You Provide Care For Person?

What Is The Major Health Problem, Illness, Disability For Care For Person?

Managed personal care

Managed household tasks

Which support do you MOST need that you are not getting?

Do you expect to have a relative you will need to provide care for?

Have you experienced confusion or memory loss that is happening more often or is getting worse?

Given up day-to-day chores due to confusion or memory loss

Need assistance with day-to_day activities due to confusion or memory loss

When you need help with day-to-day activities are you able to get it

Does confusion or memory loss interfere with work or social activities

Have you discussed your confusion or memory loss with a health care professional?

How often do you drink regular soda or pop?

How often did you drink sugar-sweetened drinks?

When calorie information is available in the restaurant, how often does this information help you decide what to order?

During the past 30 days, on how many days did you use marijuana or hashish?

During the past 30 days, how did you use marijuana?

Days had trouble with sleep

Over the last 2 weeks, how many days did you unintentionally fall asleep during the day?

Have you ever been told that you snore loudly?

Has anyone ever observed that you stop breathing during your sleep?

Age at Asthma Diagnosis

Asthma During Past 12 Months

Emergency Asthma Care During Past 12 Months

Urgent Asthma Treatment During Past 12 Months

Routine Asthma Care During Past 12 Months

Activities Limited Because of Asthma During Past 12 Months

Asthma Symptoms During Past 30 Days

Sleep Difficulty Because of Asthma During Past 30 Days

Days used prescribed preventative asthma med in past 30 days

Times used asthma inhaler during an attack in past 30 days

Where did you get your last flu shot/vaccine?

Have you ever had the HPV vaccination?

How many HPV shots did you receive?

Have you ever had the shingles or zoster vaccine?

Number Of Sunburns In Past 12 Months

How Many Types of Cancer?

Age Told Had Cancer

Type of Cancer

Currently Receiving Treatment for Cancer

What Type of Doctor Provides Majority of Your Care

Did You Receive a Summary of Cancer Treatments Received

Ever Receive Instructions From A Doctor For Follow-Up Check-Ups

Instructions Written or Printed

Did Health Insurance Pay For All Of Your Cancer Treatment

Ever Denied Insurance Coverage Because Of Your Cancer?

Participate In Clinical Trial As Part Of Cancer Treatment?

Currently Have Physical Pain From Cancer Or Treatment?

Is Pain Under Control?

Ever Had Breast Physical Exam by Doctor

How Long since Last Breast Physical Exam

Why was PSA test done?

Who made the decision with you to have PSA test?

Type of Work

Type of Business/Industry

Sexual orientation or gender identity

Do you consider yourself to be transgender?

Birth date of child

Gender of child

Ethnicity of child

Race of child (multiple possible)

Race of child

Relationship to child

Hlth pro ever said child has asthma

Child still have asthma?

How often get emotional support needed

Satisfaction with life

Activity Limitation Due to Health Problems

Health Problems Requiring Special Equipment

Asthma Follow-Up call back request

Asthma Follow-Up call back responded selected

Adult Hispanic response

Child Hispanic response

Questionnaire Version Identifier

Imputed Education Level

Language identifier

AR1_1. If you have never had your blood sugar tested for diabetes, do you know where you can go to get tested?

AR2_1 Has a health care professional ever advised you to reduce your weight?

AR2_2 Have you ever heard of Body Mass Index (BMI) measurements?

AR2_3 If yes, do you know what a healthy BMI would be for you?

AR2_4 If you would like to reduce or monitor your weight, do you know where you can get help to do this?

AR3_1 Has a health care provider ever told you that you have blood circulation problems?

AR3_2 Has a health care provider ever told you that you have high blood pressure (hypertension)?

AR3_3 If you are not sure whether you have high blood pressure, do you know where to go to get your blood pressure measured?

AR3_4 Has a health care provider ever advised you on how to reduce or prevent high blood pressure (hypertension)?

AR3_5 Has a health care provider discussed the role of diet (besides sodium reduction) in reducing or preventing high blood pressure?

AR3_6 Do you know what your blood pressure measurement should be?

AR4_1 Blood cholesterol is a fatty substance found in the blood. Have you EVER had your blood cholesterol checked?

AR4_2 About how long has it been since you last had your blood cholesterol checked?

AR4_3 Have you EVER been told by a doctor, nurse or other health professional that your blood cholesterol is high?

AR5_1 Now, looking back before you were 18 years of age, did you live with anyone who was depressed, mentally ill, or suicidal?

AR5_2 (Before you were 18 years of age), did you live with anyone who was a problem drinker or alcoholic?

AR5_3 (Before you were 18 years of age), did you live with anyone who used illegal street drugs or who abused prescription medications?

AR5_4 (Before you were 18 years of age), did you live with anyone who served time or was sentenced to serve time in a prison, jail, or other correctional facility?

AR5_5 Were your parents separated or divorced?

AR5_6 How often did your parents or adults in your home ever slap, hit, kick, punch or beat each other up? Would you say...

AR5_7 Before age 18, how often did a parent or adult in your home ever hit, beat, kick, or physically hurt you in any way? Do not include spanking.

AR5_8 How often did a parent or adult in your home ever swear at you, insult you, or put you down?

AR5_9 How often did anyone at least 5 years older than you or an adult, ever touch you sexually?

AR5_10 How often did anyone at least 5 years older than you or an adult, try to make you touch them sexually?

AR5_11 How often did anyone at least 5 years older than you or an adult, force you to have sex?

AR5close As I mentioned when we started this section, I would give you a phone number for an organization that can provide information and referral for these issues. Would you like me to give you that number?

AR6_1 How old were you when you first started smoking cigarettes fairly regularly?

AR6_2 On the average, about how many cigarettes a day do you now smoke?

AR6_3 Do you now smoke menthol cigarettes?

AR6_4 The next question asks you about smoking tobacco in a water pipe. A water pipe is also called a hookah. Have you ever tried smoking tobacco in a water pipe in your entire life, even one or two puffs?

AR6_5 In the past 12 months, that is, have you seen a doctor, dentist, nurse, or other health professional?

AR6_6 In the past 12 months, did any doctor, dentist, nurse, or other health care professional advise you to quit smoking cigarettes or using any other tobacco products?

AR6_7 The last time a health professional advised you to quit using tobacco, did they also offer any assistance, information, or additional advice to help you quit?

AR6_8 During the past 30 days, have you seen or heard of a 1-800 number on TV, radio, or elsewhere that someone can call to get information about quitting smoking?

AR6_9 During the past 30 days, on how many days did you smoke cigars, cigarillos, little cigars, or premium cigars?

"AR6_10 To what extent do you agree or disagree with the following statement:

If a non-smoker begins to use electronic cigarettes it is harmful to their health.

"AR6_11 To what extent do you agree or disagree with the following statement:

If a current cigarette smoker switches to electronic cigarettes it is harmful to their health.

AR6_12a Switching to chewing tobacco, snuff, or snus?

AR6_12b Switching to electronic cigarettes?

AR6_12c Quitting cold turkey?

Trauma Registry

PATIENT'S FIRST 3 NUMBERS OF ZIP CODE

PATIENT'S HOME STATE

PATIENT'S HOME COUNTY

PATIENT'S HOME CITY

AGE

AGE UNITS

RACE

ETHNICITY

SEX

INJURY INCIDENT DATE

INJURY INCIDENT TIME

INJURY TYPE

WORK RELATED

PATIENT'S OCCUPATION

PATIENT'S OCCUPATIONAL INDUSTRY

ICD-10 PRIMARY EXTERNAL CAUSE CODE

ICD-10 PLACE OF OCCURRENCE EXTERNAL CAUSE CODE

ICD-10 ADDITIONAL EXTERNAL CAUSE CODE

INCIDENT CITY

INCIDENT COUNTY

INCIDENT STATE

INCIDENT COUNTRY

INCIDENT FIRST 3 NUMBERS OF ZIP CODE

PROTECTIVE DEVICES

CHILD SPECIFIC RESTRAINT

AIRBAG DEPLOYMENT

REPORT OF PHYSICAL ABUSE

INVESTIGATION OF PHYSICAL ABUSE

TRANSPORT MODE

OTHER TRANSPORT MODE - SPECIFY

EMS NOTIFY DATE

EMS NOTIFY TIME

EMS DISPATCH DATE

EMS DISPATCH TIME

EMS RESPOND DATE

EMS RESPOND TIME

EMS UNIT ARRIVAL DATE

EMS UNIT ARRIVAL TIME

EMS DEPARTURE DATE

EMS DEPARTURE TIME

EMS ARRIVAL DESTINATION DATE

EMS ARRIVAL DESTINATION TIME

REASON FOR DESTINATION HOSPITAL

SCENE RELATED DELAYS

INITIAL FIELD SYSTOLIC BLOOD PRESSURE

INITIAL FIELD PULSE RATE

INITIAL FIELD RESPIRATORY RATE

INITIAL FIELD RESPIRATORY ASSISTANCE

INITIAL FIELD OXYGEN SATURATION

INITIAL FIELD SUPPLEMENTAL OXYGEN

INITIAL FIELD GCS - EYE

INITIAL FIELD GCS - VERBAL

INITIAL FIELD GCS - MOTOR

INITIAL FIELD GCS - TOTAL

INITIAL FIELD GCS ASSESSMENT QUALIFIERS

TRAUMA CENTER CRITERIA

PEDESTRIAN, OTHER RISK INJURY

INTERFACILITY TRANSFER

TRANSFER MODE

REFERRING HOSPITAL ARRIVAL DATE

REFERRING HOSPITAL ARRIVAL TIME

REFERRING HOSPITAL DISCHARGE DATE

REFERRING HOSPITAL DISCHARGE TIME

REFERRING HOSPITAL SYSTOLIC BLOOD PRESSURE

REFERRING HOSPITAL PULSE RATE

REFERRING HOSPITAL RESPIRATION RATE

REFERRING HOSPITAL GCS - EYE

REFERRING HOSPITAL GCS - VERBAL

REFERRING HOSPITAL GCS - MOTOR

REFERRING HOSPITAL GCS - TOTAL

REFERRING FACILITY GCS ASSESSMENT QUALIFIERS

ED ARRIVED FROM

ED ARRIVAL MODE

ED DIRECT ADMIT

ED READMISSION

ED/HOSPITAL ARRIVAL DATE

ED/HOSPITAL ARRIVAL TIME

INITIAL ED/HOSPITAL SYSTOLIC BLOOD PRESSURE

INITIAL ED/HOSPITAL PULSE RATE

INITIAL ED/HOSPITAL TEMPERATURE

TEMPERATURE UNITS

INITIAL ED/HOSPITAL RESPIRATORY RATE

INITIAL ED/HOSPITAL RESPIRATORY ASSISTANCE

INITIAL ED/HOSPITAL OXYGEN SATURATION

INITIAL ED/HOSPITAL SUPPLEMENTAL OXYGEN

INITIAL ED/HOSPITAL HEIGHT

INITIAL ED/HOSPITAL HEIGHT UNITS

INITIAL ED/HOSPITAL WEIGHT

INITIAL ED/HOSPITAL WEIGHT UNITS

INITIAL ED/HOSPITAL GLASGOW COMA SCALE (GCS) - EYE

INITIAL ED/HOSPITAL GLASGOW COMA SCALE (GCS) - VERBAL

INITIAL ED/HOSPITAL GLASGOW COMA SCALE (GCS) - MOTOR

INITIAL ED/HOSPITAL GLASGOW COMA SCALE (GCS) - TOTAL

INITIAL ED/HOSPITAL GLASGOW COMA SCALE ASSESSMENT QUALIFIERS

DRUG SCREEN

ALCOHOL SCREEN

ALCOHOL SCREEN RESULTS

ED DISCHARGE DISPOSITION

SIGNS OF LIFE

ED DEATH DETAILS

ED DISCHARGE DATE

ED DISCHARGE TIME

ED DISCHARGE ORDER DATE

ED DISCHARGE ORDER TIME

TRAUMA TEAM ACTIVATION

TRAUMA TEAM ACTIVATION LEVEL

SURGEON CALLED TIME

SURGEON ARRIVED TIME

TRAUMA TEAM ACTIVATION DATE

TRAUMA TEAM ACTIVATION TIME

ARKANSAS TRAUMA COMMUNICATIONS CENTER (ATCC) UTILIZATION (SENDING FACILITY ONLY)

ATCC DATE OF CONTACT (SENDING FACILITY ONLY)

ATCC TIME OF CONTACT (SENDING FACILITY ONLY)

PATIENT TRANSFER MODE (SENDING FACILITY ONLY)

HOSPITAL ADMITTING SERVICE

ED/HOSPITAL CARE ISSUES

ICD-10 HOSPITAL PROCEDURES

HOSPITAL PROCEDURE START DATE

HOSPITAL PROCEDURE START TIME

OR DISPOSITION

ANTIBIOTICS

ANTIBIOTICS START DATE

ANTIBIOTICS START TIME

HEAD CT SCAN

ANTICOAGULANTS AT HOME

ICD-10 INJURY DIAGNOSIS

ICD-10 CODE

AIS PREDOT CODE

AIS SEVERITY

AIS VERSION

ISS BODY REGION

ISS

TRISS

PRE HOSPITAL CARDIAC ARREST

CO-MORBID CONDITIONS

HOSPITAL COMPLICATIONS

TOTAL ICU DAYS

TOTAL VENTILATOR SUPPORT DAYS

TOTAL HOSPITAL DAYS

HOSPITAL DISCHARGE DATE

HOSPITAL DISCHARGE TIME

HOSPITAL DISPOSITION

LIFE SUPPORT WITHDRAWN

ORGAN DONATION

ORGANS DONATED

AUTOPSY DONE

AUTOPSY RESULTS REQUESTED

AUTOPSY RESULTS RECEIVED

CONSULTS

GOS: GLASGOW OUTCOME SCALE

PRIMARY METHOD OF PAYMENT

SECONDARY METHOD OF PAYMENT

HIGHEST GCS TOTAL

INITIAL ED/HOSPITAL PUPILLARY RESPONSE

MIDLINE SHIFT

HIGHEST GCS MOTOR

GCS ASSESSMENT QUALIFIER COMPONENT OF HIGHEST GCS TOTAL

CEREBRAL MONITOR

CEREBRAL MONITOR DATE

CEREBRAL MONITOR TIME

VENOUS THROMBOEMBOLISM PROPHYLAXIS TYPE

VENOUS THROMBOEMBOLISM PROPHYLAXIS DATE

VENOUS THROMBOEMBOLISM PROPHYLAXIS TIME

LOWEST ED/HOSPITAL SBP

WITHDRAWAL OF LIFE SUPPORTING TREATMENT

WITHDRAWAL OF LIFE SUPPORTING TREATMENT DATE

WITHDRAWAL OF LIFE SUPPORTING TREATMENT TIME

Cancer Registry

Description

Name of the city in which the patient resides at the time of diagnosis.

USPS abbreviation for the state, territory, commonwealth, U.S. possession, or CanadaPost abbreviation for the Canadian province/territory in which the patient resides at the time of diagnosis.

Code for the county of the patient's residence at the time of diagnosis.

Code for the county of the patient's residence at the time the tumor was diagnosed is a derived (geocoded) variable based on Census Boundary files from 1990 Decennial Census.

Code for the county of the patient's residence at the time the tumor was diagnosed is a derived (geocoded) variable based on Census Boundary files from 2000 Decennial Census.

Code for the county of the patient's residence at the time the tumor was diagnosed is a derived (geocoded) variable based on Census Boundary files from 2010 Decennial Census.

Code for the county of the patient's residence at the time the tumor was diagnosed is a derived (geocoded) variable based on Census Boundary files from 2020 Decennial Census.

Postal code for the address of the patient's residence at the time of diagnosis.

Country code for the address of the patient's residence at the time the reportable tumor is diagnosed.

Code for the census tract or BNA of the patient's residence at the time of diagnosis.

Identified the set of Census Bureau census tract definitions (boundaries) that were used to code the census tract in Census Tract 1970/80/90 [110] for a specific record.

This field is provided for coding census tract (using 2000 census data) of patient's residence at time of diagnosis.

This field is provided for coding census tract (using 2010 census data) of patient's residence at time of diagnosis.

Assigns a code for neighborhood poverty level based on the census tract of diagnosis address.

Code the patient's race.

Code identifying persons of Spanish or Hispanic origin.

The NAACCR Hispanic Identification Algorithm (NHIA) uses a combination of standard variables to directly or indirectly classify cases as Hispanic for analytic purposes.

This variable captures the results of the linkage of the registry database with the Indian Health Service patient registration database.

The NAACCR Asian/Pacific Islander Identification Algorithm (NAPIIA) uses a combination of standard variables to directly or indirectly classify cases as asian/pacific islander for analytic purposes.

Code identifying those cases for which ethnicity was determined by matching Name--Last [2230] and Name--Maiden [2390] to a computer list of Spanish/Hispanic names or by a software algorithm.

Code identifying the method used to determine ethnicity as recorded in Computed Ethnicity [200].

Code for the sex of the patient.

Age of the patient at diagnosis in complete years.

Date of birth of the patient.

This flag explains why there is no appropriate value in the corresponding date field, Date of Birth [240].

Code for place of birth of the patient.

USPS abbreviation for the state, commonwealth, U.S. possession; or CanadaPost abbreviation for the Canadian province/territory in which the patient was born.

Code for the country in which the patient was born.

Code for the patient's usual occupation, using U.S. Census Bureau codes (2000 Census26 is preferable) according to coding procedures recommended for death certificates.

Code for the patient's usual industry, using U.S. Census Bureau codes (see note below) according to coding procedures recommended for death certificates.

Code for the patient's usual industry, using U.S. Census Bureau codes (2000 Census26 is preferable) according to coding procedures recommended for death certificates.

Code for the patient's usual occupation, using U.S. Census Bureau codes (see note below) according to coding procedures recommended for death certificates.

Code that best describes the source of occupation information provided on this patient.

Code that best describes the source of industry information provided on this patient.

Text area for information about the patient's usual occupation, also known as usual type of job or work.

Text area for information about the patient's usual industry, also known as usual kind of business/industry.

Use of tobacco by patient.

History of alcohol consumption by patient.

Family history of cancer.

This field is provided for coding the block group of patient's residence at time of diagnosis, as defined by the 2000 Census.

This field is provided for coding the block group of patient's residence at time of diagnosis, as defined by the 2010 Census.

Code indicating basis of assignment of census tract or block numbering area (BNA) for an individual record.

Code indicating basis of assignment of census tract for an individual record.

Code indicating the basis of assignment of latitude and longitude coordinates for an individual record from an address.

Code indicating basis of assignment of census tract for an individual record.

This field is provided for coding the block group of patient's residence at time of diagnosis, as defined by the 1970, 1980, or 1990 Census.

Code indicates the sequence of all reportable neoplasms over the lifetime of the person.

Date of initial diagnosis by a recognized medical practitioner for the tumor being reported whether clinically or microscopically confirmed.

This flag explains why there is no appropriate value in the corresponding date field, Date of Diagnosis [390].

Code for the primary site of the tumor being reported using either ICD-O-2 or ICD-O-3.

Code for the side of a paired organ, or the side of the body on which the reportable tumor originated.

Codes for the histologic type of the tumor being reported using ICD-O-2.

Code for the behavior of the tumor being reported using ICD-O-2.

This flag explains why there is no appropriate value in the corresponding date field, Date of Multiple Tumors [445].

Code for the grade or degree of differentiation of the reportable tumor.

Identifies all cases, including death certificate only and autopsy only, for which an ambiguous term is the most definitive word or phrase used to establish a cancer diagnosis.

Documents the date when a conclusive cancer diagnosis (definite statement of malignancy) is made following an initial diagnosis that was based only on ambiguous terminology.

This data item is used to identify the type of multiple tumors in cases with multiple tumors that are abstracted and reported as a single primary using the SEER, IARC, or Canadian Cancer Registry multiple primary rules.

This data item is used to identify the month, day and year the patient is diagnosed with multiple tumors reported as a single primary using the SEER, IARC, or Canadian Cancer Registry multiple primary rules.

This data item is used to count the number of tumors (multiplicity) that are reported as a single primary, when present at the time of diagnosis or occurring later.

This flag explains why there is no appropriate value in the corresponding date field, Date of Conclusive DX [443].

Code for the best method of diagnostic confirmation of the cancer being reported at any time in the patient's history.

This variable codes the source documents used to abstract the majority of information on the tumor being reported. This may not be the source of original case finding.

This variable codes the earliest source of identifying information.

Codes for the histologic type of the tumor being reported using ICD-O-3.

Code for the behavior of the tumor being reported using ICD-O-3.

This data item records the most accurate measurement of a solid primary tumor, usually measured on the surgical resection specimen.

Code for summary stage at the initial diagnosis or treatment of the reportable tumor.

Site-specific EOD codes provide extensive detail describing disease extent.

Detailed site-specific codes for anatomic EOD used by SEER for tumors diagnosed from 1988 forward.

This is an additional field for prostate cancer only to reflect information from radical prostatectomy, effective with 1995 diagnoses.

Site-specific EOD codes provide extensive detail describing disease extent.

Records the exact number of regional nodes examined by the pathologist and found to contain metastases.

Records the total number of regional lymph nodes that were removed and examined by the pathologist.

Detailed site-specific codes for the pathologic tumor (T) as defined by AJCC and recorded by the physician.

Detailed site-specific codes for the pathologic nodes (N) as defined by AJCC and recorded by physician.

Detailed site-specific codes for the pathologic metastases (M) as defined by AJCC and recorded by the physician.

Detailed site-specific codes for the pathologic stage group as defined by AJCC and recorded by the physician.

Identified the AJCC clinical stage (prefix/suffix) descriptor as recorded by the physician.

Identifies the person who recorded the pathologic AJCC staging elements and the stage group in the patient's medical record.

Detailed site-specific codes for the clinical tumor (T) as defined by AJCC and recorded by the physician.

Detailed site-specific codes for the clinical nodes (N) as defined by AJCC and recorded by the physician.

Detailed site-specific codes for the clinical metastases (M) as defined by AJCC and recorded by the physician.

Detailed site-specific codes for the clinical stage group as defined by AJCC and recorded by the physician.

Identifies the AJCC clinical stage (prefix/suffix) descriptor as recorded by the physician.

Identifies the person who recorded the clinical AJCC staging elements and the stage group in the patient's medical record.

A code that indicates the edition of the AJCC manual used to stage the case.

Codes for a site of distant metastases.

This field identifies whether bone is an involved metastatic site. The six Mets at Dx-Metastatic Sites fields provide information on specific metastatic sites for data analysis.

This field identifies whether brain is an involved metastatic site. The six Mets at Dx-Metastatic Sites fields provide information on specific metastatic sites for data analysis.

This field identifies whether distant lymph node(s) is an involved metastatic site. The six Mets at Dx-Metastatic Sites fields provide information on specific metastatic sites for data analysis.

This field identifies whether liver is an involved metastatic site. The six Mets at Dx-Metastatic Sites fields provide information on specific metastatic sites for data analysis.

This field identifies whether lung is an involved metastatic site. The six Mets at Dx-Metastatic Sites fields provide information on specific metastatic sites for data analysis.

This field identifies whether other metastatic involvement, other than bone, brain, liver, lung or distant lymph nodes exists. Some examples include but are not limited to the adrenal gland, bone marrow, pleura, peritoneum and skin. The six Mets at Dx-Metastatic Sites fields provide information on specific metastatic sites for data analysis.

Records prognostic indicators for specific sites or histologies.

Indicates whether lymph-vascular invasion (LVI) is identified in the pathology report.

Date the first surgery of the type described under Surgery of Primary Site, Scope of Regional Lymph Node Surgery, or Surgery of Other Regional Site(s), Distant Site(s) or Distant Lymph Nodes was performed.

This flag explains why there is no appropriate value in the corresponding date field, RX Date--Surgery [1200].

Records the date on which radiation therapy began at any facility that is part of the first course of treatment.

This flag explains why there is no appropriate value in the corresponding date field, RX Date--Radiation [1210].

Date of initiation of chemotherapy that is part of the first course of treatment.

This flag explains why there is no appropriate value in the corresponding date field, RX Date--Chemo [1220].

Date of initiation for hormone therapy that is part of the first course of treatment.

This flag explains why there is no appropriate value in the corresponding date field, RX Date--Hormone [1230].

Date of initiation for immunotherapy (a.k.a. biological response modifier) that is part of the first course of treatment.

This flag explains why there is no appropriate value in the corresponding date field, RX Date--BRM [1240].

Date of initiation for other treatment that is part of the first course of treatment at any facility.

This flag explains why there is no appropriate value in the corresponding date field, RX Date--Other [1250].

Date of initiation of the first therapy for the cancer being reported, using the CoC definition of first course.

This flag explains why there is no appropriate value in the corresponding date field, Date of 1st Crs RX [1270].

Records the date on which the surgical diagnostic and/or staging procedure was performed.

This flag explains why there is no appropriate value in the corresponding date field, RX Date--DX/Stg Proc [1280].

This data item is a summary of the status for all treatment modalities.

Site-specific codes for the type of surgery to the primary site performed as part of the first course of treatment.

Describes the removal, biopsy or aspiration of regional lymph node(s) at the time of surgery of the primary site or during a separate surgical event at all facilities.

Records the surgical removal of distant lymph nodes or other tissue(s)/organ(s) beyond the primary site.

Codes for the number of regional lymph nodes examined in conjunction with surgery performed as part of the first-course treatment.

Codes for method used to approach the surgical field for the primary site.

Codes describe the final status of surgical margins after resection of the primary tumor.

Codes for surgical procedures done to reconstruct, restore, or improve the shape and appearance or function of body structures that are missing, defective, damaged, or misshapen by cancer or therapies.

Records the reason that no surgery was performed on the primary site.

Identifies the surgical procedure(s) performed in an effort to diagnose and/or stage disease.

Codes for the type of radiation therapy performed as part of the first course of treatment.

Codes for the sequencing of radiation and surgery given as part of the first course of treatment.

Codes for chemotherapy given as part of the first course of treatment or the reason chemotherapy was not given.

Records whether systemic hormonal agents were administered as first-course treatment at any facility, or the reason they were not given.

Records whether immunotherapeutic (biologic response modifiers) agents were administered as first-course treatment at all facilities or the reason they were not given.

Identifies other treatment given at all facilities that cannot be defined as surgery, radiation, or systemic therapy according to the defined data items in this manual.

Code the reason the patient did not receive radiation treatment as part of first course of therapy.

The dominant or most clinically significant total dose of regional radiation therapy delivered to the patient during the first course of treatment.

Records the total number of treatment sessions (fractions) administered during the first course of therapy.

Identifies the volume or anatomic target of the most clinically significant regional radiation therapy delivered to the patient during the first course of therapy.

Identifies the location of the facility where radiation treatment was administered during first course of treatment.

Records the dominant modality of radiation therapy used to deliver the clinically most significant regional dose to the primary volume of interest during the first course of treatment.

Records the sequencing of systemic therapy (RX Summ-Chemo [1390], RX Summ-Hormone [1400], RX Summ-BRM [1410], and RX Summ-Transplnt/Endocr [3250]) and surgical procedures given as part of the first course of treatment.

Field for pre-1996 surgery codes for CoC and pre-1998 surgery codes for SEER.

Site-specific codes for the type of surgery to the primary site performed as part of the first course of treatment.

Describes the removal, biopsy or aspiration of regional lymph node(s) at the time of surgery of the primary site or during a separate surgical event at all facilities.

Records the surgical removal of distant lymph nodes or other tissue(s)/organ(s) beyond the primary site given at all facilities as part of the first course of treatment.

Date of last contact with the patient, or date of death.

This flag explains why there is no appropriate value in the corresponding date field, Date of Last Contact [1750].

Vital status of the patient as of the date entered in Date of Last Contact [1750].

Records the presence or absence of clinical evidence of the patient's malignant or non-malignant tumor as of the Date of Last Contact.

The Surv-Date Active Followup is defined as the earlier of the Date of Last Contact and a study cutoff date. The study cut-off date is a pre-determined date based on the year of data submission and is set in the survival program used to derive the seven survival variables.

This flag is generated by the program that creates Surv-Mos Active Followup [1784] and describes how complete the date information is that was used to calculate survival months. This item is one of seven survival variables designed to facilitate a common approach to survival analysis by NAACCR registries.

The survival interval in months is calculated using the month, day, and year of the Surv-Date DX Recode [1788] and the month, day, and year of the Surv-Date Active Followup [1782]. The survival interval is calculated by a program available from your standard setter or NAACCR.

This field is the last date for which complete death ascertainment is available from the registry at the time a file is transmitted. Because not all central cancer registries conduct active patient follow-up, it is necessary to have an option for calculating survival times based on the assumption that the registry has ascertained all available deaths, and persons not known to be deceased are presumed to be alive as of the last date for which complete death ascertainment is available.

This flag is generated by the program that creates Surv-Mos Presumed Alive [1787] and describes how complete the date information is that was used to calculate survival months. This item is one of seven survival variables designed to facilitate a common approach to survival analysis by NAACCR registries.

Because not all central cancer registries conduct active patient follow-up, it is necessary to have an option for calculating survival times based on the assumption that the registry has ascertained all available deaths (state/province and national), and persons not known to be deceased are presumed to be alive as of the last date for which complete death ascertainment is available.

The survival date of diagnosis recode is calculated using the month, day, and year of the Date of Diagnosis [390]. If the Date of Diagnosis [390] has complete month and day information, the Surv-Date Dx Recode will be the same as the Date of Diagnosis [390]. If the day or month is unknown or not available, the values are imputed by the survival program used to derive the seven survival variables.

Records the source from which the latest follow-up information was obtained.

This field is created by the central registry.

Identifies the method planned for the next follow-up.

Name of city of the patient's current usual residence.

USPS abbreviation for the state, territory, commonwealth, U.S. possession, or CanadaPost abbreviation for the Canadian province/territory of the patient's current usual residence.

Postal code for the address of the patient's current usual residence.

Country code for the address of patient's current usual residence.

The date of the first recurrence of this tumor.

This flag explains why there is no appropriate value in the corresponding date field, Recurrence Date--1st [1860].

Code for the distant site or sites in which the reportable tumor has recurred.

Code for the type of first recurrence after a period of documented disease free intermission or remission.

Official cause of death as coded from the death certificate in valid ICD-7, ICD-8, ICD-9, and ICD-10 codes.

Indicator for the coding scheme used to code the cause of death.

State or country where the patient died and where certificate of death is filed.

State or Province where the patient died and where certificate of death is filed.

Code for the country in which the patient died and where certificate of death is filed.

Code specifying how the conversion of site and morphology codes from ICD-O-1 and the field trial editions to ICD-O-2 was accomplished.

Date the record was last changed or updated.

Date the demographic and tumor identification information on a single primary/reportable neoplasm is available in the central cancer registry database to be counted as an incident tumor.

Code specifying how the conversion of site and morphology codes from ICD-O-2 to ICD-O-3 was accomplished.

For most sites, CS Tumor Size is used to record the largest dimension, or the diameter of the primary tumor in millimeters

CS Extension identifies the primary tumor growth within the organ of origin or its extension into neighboring organs.

CS Tumor Size/Ext Eval records how the codes for CS Tumor Size [2800] and CS Extension [2810] were determined based on the diagnostic methods employed.

CS Lymph Nodes is site-specific and identifies the regional lymph nodes involved with cancer at the time of diagnosis.

CS Lymph Nodes Eval records how the code for the item CS Lymph Nodes [2830] was determined based on the diagnostic methods employed.

CS Metastasis at Diagnosis identifies the site(s) of metastatic involvement at time of diagnosis.

CS Mets at Dx-Bone describes whether the bone is involved as a metastatic site.

CS Mets at Dx-Brain describes whether the brain is involved as a metastatic site.

CS Mets at Dx-Liver describes whether the liver is involved as a metastatic site.

CS Mets at Dx-Lung describes whether the lung is involved as a metastatic site.

CS Mets Eval records how the code for item CS Mets at DX [2850] was determined based on the diagnostic methods employed.

The CS Site-Specific Factor items (1-25) are used to code additional site-specific information needed to derive TNM or AJCC stage, or to code prognostic factors that have an effect on stage or survival.

This item indicates the number of the version used to initially code the CS input fields.

This item indicates the number of the version of the CS used most recently to derive the CS output fields.

This item indicates the number of the version after CS input fields have been updated or recoded.

This field contains the numeric representation for the AJCC 6th edition "T" and is derived from CS coded fields using the CS algorithm.

This field contains the numeric representation for the AJCC 6th edition "T Descriptor" and is derived from CS coded fields using the CS algorithm.

This field contains the numeric representation for AJCC 6th edition "N" and is derived from CS coded fields using the CS algorithm.

This field contains the numeric representation for AJCC 6th edition "N Descriptor" and is derived from CS coded fields using the CS algorithm.

This field contains the numeric representation for AJCC 6th edition "M" and is derived from CS coded fields using the CS algorithm.

This field contains the numeric representation for AJCC 6th edition "M Descriptor" and is derived from CS coded fields using the CS algorithm.

This field contains the numeric representation for the AJCC 6th edition "Stage Group" and is derived from CS coded fields using the CS algorithm.

This item is the derived "SEER Summary Stage 1977" from the CS algorithm (or EOD codes) effective with 2004 diagnosis.

This item is the derived "SEER Summary Stage 2000" from the CS algorithm (or EOD codes) effective with 2004 diagnosis.

Flag to indicate whether the derived AJCC stage was derived from CS or EOD codes.

Flag to indicate whether the derived SEER Summary Stage 1977 was derived from CS or EOD codes.

Flag to indicate whether the derived SEER Summary Stage 2000 was derived from CS or EOD codes.

Records the patient's pre-existing medical conditions, factors influencing health status, and/or complications during the patient's hospital stay for the treatment of this cancer using ICD-9-CM codes.

This item indicates the coding system in which the Comorbidities and Complications (secondary diagnoses) codes are provided.

Date of most definitive surgical resection of the primary site performed as part of the first course of treatment.

This flag explains why there is no appropriate value in the corresponding date field, RX Date--Most Defin Surg [3170].

Records the date the patient was discharged following primary site surgery.

This flag explains why there is no appropriate value in the corresponding date field, RX Date--Surgical Disch [3180].

Records a readmission to the same hospital within 30 days of discharge following hospitalization for surgical resection of the primary site for the same illness.

Records the dominant modality of radiation therapy used to deliver the most clinically significant boost dose to the primary volume of interest during the first course of treatment.

Records the additional dose delivered to that part of the treatment volume encompassed by the boost fields or devices. The unit of measure is centiGray (cGy).

The date on which the patient completes or receives the last radiation treatment at any facility.

This flag explains why there is no appropriate value in the corresponding date field, RX Date--Radiation Ended [3220].

Date of initiation of systemic therapy that is part of the first course of treatment.

This flag explains why there is no appropriate value in the corresponding date field, RX Date--Systemic [3230].

Identifies systemic therapeutic procedures administered as part of the first course of treatment at this and all other facilities.

Identifies any care provided in an effort to palliate or alleviate symptoms.

The RuralUrban Continuum [1993] codes (usually known as the Beale Codes) separate counties into four metropolitan and six non-metropolitan categories.

The RuralUrban Continuum [2003] codes (usually known as the Beale Codes) separate counties into four metropolitan and six non-metropolitan categories.

The RuralUrban Continuum (2013) codes separate counties into four metropolitan and six non-metropolitan categories, based on the size their populations and form a classification scheme that distinguishes metropolitan counties by size and non-metropolitan counties by degree of urbanization and proximity to metro areas.

This field contains the numeric representation for the AJCC 7th edition "T" and is derived from CS coded fields using the CS algorithm.

This field contains the numeric representation for the AJCC 7th edition "T Descriptor" and is derived from CS coded fields using the CS algorithm.

This field contains the numeric representation for the AJCC 7th edition "N" and is derived from CS coded fields using the CS algorithm.

This field contains the numeric representation for the AJCC 7th edition "N Descriptor" and is derived from CS coded fields using the CS algorithm.

This field contains the numeric representation for the AJCC 7th edition "M" and is derived from CS coded fields using the CS algorithm.

This field contains the numeric representation for the AJCC 7th edition "M Descriptor" and is derived from CS coded fields using the CS algorithm.

This field contains the numeric representation for the AJCC 7th edition "Stage Group" and is derived from CS coded fields using the CS algorithm.

This data item is needed to store the results of the derived algorithmic calculation of Derived SEER Pathologic Stage Group.

This data item is needed to store the results of the derived algorithmic calculation of Derived SEER Clinical Stage Group.

This new data item is needed to store the results of the derived algorithmic calculation of Derived SEER Combined T.

This item is used to store the results of the source information selected for the derived algorithmic calculation of Combined T, N, and M.

This item is needed to store the results of the source information selected for the derived algorithmic calculation of Derived SEER Combined T [3616].

This item is needed to store the results of the source information selected for the derived algorithmic calculation of Derived SEER Combined N [3618].

This item is needed to store the results of the source information selected for the derived algorithmic calculation of Derived SEER Combined M [3620].

This item is needed to store the results of NPCR's derived algorithmic calculation of clinical stage group based on AJCC T, N, and M and relevant biomarkers and prognostic factors.

This item is needed to store the results of NPCR's derived algorithmic calculation of pathological stage group based on AJCC T, N, and M and relevant biomarkers and prognostic factors.

Records the patient's preexisting medical conditions, factors influencing health status, and/or complications during the patient's hospital stay for the treatment of this cancer.

HDDS_ED

CITY

STATE

FIRST 3 NUMBERS OF ZIP CODE

FIPS CODE

COUNTY

AGE

GENDER

RACE

ETHNICITY

MARITAL STATUS

ADMISSION DATE

TOTAL CHARGES

ADMISSION HOUR

DISCHARGE HOUR

TYPE OF ADMISSION

SOURCE OF ADMISSION

DISCHARGE STATUS

ECODE1

ECODE2

ECODE3

DIAG1 (DIAGNOSIS CODE)

DIAG2

DIAG3

DIAG4

DIAG5

DIAG6

DIAG7

DIAG8

DIAG9

DIAG10

DIAG11

DIAG12

DIAG13

DIAG14

DIAG15

DIAG16

DIAG17

DIAG18

POA1 (DIAGNOSIS CODE PRESENT UPON ADMISSION)

POA2

POA3

POA4

POA5

POA6

POA7

POA8

POA9

POA10

POA11

POA12

POA13

POA14

POA15

POA16

POA17

POA18

PROCEDURE CODE METHOD)

PROC1 (PROCEDURE CODE)

PROC1DAY (DAY OF PROCEDURE)

PROC2

PROC2DAY

PROC3

PROC3DAY

PROC4

PROC4DAY

PROC5

PROC5DAY

PROC6

PROC6DAY

PROC7

PROC7DAY

PROC8

PROC8DAY

FIRST SOURCE OF PAYMENT

SECOND SOURCE OF PAYMENT

THIRD SOURCE OF PAYMENT

PATIENT RELATION TO INSURED 1

PATIENT RELATION TO INSURED 2

PATIENT RELATION TO INSURED 3

PAYER ID1

PAYER ID2

PAYER ID3

PATIENT AGE

PATIENT AGE IN DAYS

LENGTH OF STAY

CMB1 (COMORBID: CHF)

CMB2 (VALVULAR DISEASE)

CMB3 (PULMONARY CIRC. DISEASE)

CMB4 (PERIPHERAL VASCULAR DISEASE)

CMB6 (PARALYSIS)

CMB7 (OTHER NEUROLOGICAL DISORDERS)

CMB8 (CHRONIC PULMONARY DISEASE)

CMB9 (DIABETES W/O COMPLICATIONS)

CMB10 (DIABETES W/ COMPLICATIONS)

CMB11 (HYPOTHYROIDISM)

CMB12 (RENAL FAILURE)

CMB13 (LIVER DISEASE)

CMB14 (PEPTIC ULCER DISEASE)

CMB15 (AIDS)

CMB16 (LYMPHOMA)

CMB17 (METASTATIC CANCER)

CMB18 (SOLID TUMOR W/O METASTASIS)

CMB19 (RHEUMATOID ARTHRITIS)

CMB20 (COAGULOPATHY)

CMB21 (OBESITY)

CMB22 (WEIGHT LOSS)

CMB23 (FLUID/ELECTROLYTE DISORDERS)

CMB24 (CHRONIC BLOOD LOSS/ANEMIA)

CMB25 (DEFICIENCY ANEMIAS)

CMB26 (ALCOHOL ABUSE)

CMB27 (DRUG ABUSE)

CMB28 (PSYCHOSES)

CMB29 (DEPRESSION)

NUMBER OF DIAGNOSES

CMB5 (HYPERTENSION)

NUMBER OF COMORBIDITIES

HCPCS1 (HCPCS PROCEDURE CODE)

HCPCS2

HCPCS3

HCPCS4

HCPCS5

HCPCS6

HCPCS7

HCPCS8

HCPCS9

HCPCS10

HCPCS11

HCPCS12

HCPCS13

HCPCS14

HCPCS15

HCPCS16

HCPCS17

HCPCS18

HCPCS19

HCPCS20

HCPCS21

HCPCS22

HCPCS23

HCPCS24

HCPCS25

HCPCS26

HCPCS27

HCPCS28

HCPCS29

HCPCS30

HCPCS31

HCPCS32

HCPCS33

HCPCS34

HCPCS35

HCPCS36

HCPCS37

HCPCS38

HCPCS39

HCPCS40

HCPCS41

HCPCS42

HCPCS43

HCPCS44

HCPCS45

HCPCS46

HCPCS47

HCPCS48

HCPCS49

HCPCS50

HCPCS51

HCPCS52

HCPCS53

HCPCS54

HCPCS55

HCPCS56

HCPCS57

HCPCS58

HCPCS59

HCPCS60

HCPCS61

HCPCS62

HCPCS63

HCPCS64

HCPCS65

HCPCS66

HCPCS67

HCPCS68

HCPCS69

HCPCS70

HDDS_Inpatient

SOURCE OF PAYMENT

STATE

FIRST 3 NUMBERS OF ZIP CODE

FIPS CODE

AGE

GENDER

RACE

ETHNICITY

MARITAL STATUS

ADMISSION DATE

TOTAL CHARGE

ADMISSION HOUR

DISCHARGE HOUR

TYPE OF ADMISSION

SOURCE OF ADMISSION

DISCHARGE STATUS

ADMITTING DIAGNOSIS

ECODE1

ECODE2

ECODE3

ECODE4

ECODE5

ECODE6

ECODE7

ECODE8

ECODE9

ECODE10

DIAG1 (DIAGNOSIS CODE)

DIAG2

DIAG3

DIAG4

DIAG5

DIAG6

DIAG7

DIAG8

DIAG9

DIAG10

DIAG11

DIAG12

DIAG13

DIAG14

DIAG15

DIAG16

DIAG17

DIAG18

DIAG19

DIAG20

DIAG21

DIAG22

DIAG23

DIAG24

DIAG25

DIAG26

DIAG27

DIAG28

DIAG29

DIAG30

POA1 (DIAGNOSIS CODE PRESENT UPON ADMISSION)

POA2

POA3

POA4

POA5

POA6

POA7

POA8

POA9

POA10

POA11

POA12

POA13

POA14

POA15

POA16

POA17

POA18

POA19

POA20

POA21

POA22

POA23

POA24

POA25

POA26

POA27

POA28

POA29

POA30

PROCEDURE CODE METHOD

PROC1 (PROCEDURE CODE)

PROC1DAY (DAY OF PROCEDURE)

PROC2

PROC2DAY

PROC3

PROC3DAY

PROC4

PROC4DAY

PROC5

PROC5DAY

PROC6

PROC6DAY

PROC7

PROC7DAY

PROC8

PROC8DAY

PROC9

PROC9DAY

PROC10

PROC10DAY

PROC11

PROC11DAY

PROC12

PROC12DAY

PROC13

PROC13DAY

PROC14

PROC14DAY

PROC15

PROC15DAY

PROC16

PROC16DAY

PROC17

PROC17DAY

PROC18

PROC18DAY

PROC19

PROC19DAY

PROC20

PROC20DAY

PROC21

PROC21DAY

SECOND PAYMENT SOURCE

THIRD PAYMENT SOURCE

PATIENT RELATION TO INSURED 1

PATIENT RELATION TO INSURED 2

PATIENT RELATION TO INSURED 3

PAYER ID1

PAYER ID2

PAYER ID3

PHCC1 (PUBLIC HEALTH CONDITION CODE)

PHCC2

PHCC3

PHCC4

HCPCS21 (HCPCS PROCEDURE CODE)

HCPCS22

HCPCS23

HCPCS24

HCPCS25

HCPCS26

HCPCS27

HCPCS28

HCPCS29

HCPCS30

HCPCS31

HCPCS32

HCPCS33

HCPCS34

HCPCS35

HCPCS36

HCPCS37

HCPCS38

HCPCS39

HCPCS40

HCPCS41

HCPCS42

HCPCS43

HCPCS44

HCPCS45

HCPCS46

HCPCS47

HCPCS48

HCPCS49

HCPCS50

HCPCS51

HCPCS52

HCPCS53

HCPCS54

HCPCS55

HCPCS56

HCPCS57

HCPCS58

HCPCS59

HCPCS60

HCPCS61

HCPCS62

HCPCS63

HCPCS64

HCPCS65

HCPCS66

HCPCS67

HCPCS68

HCPCS69

HCPCS70

HCPCS71

HCPCS72

HCPCS73

HCPCS74

HCPCS75

HCPCS76

HCPCS77

HCPCS78

HCPCS79

HCPCS80

HCPCS81

HCPCS82

HCPCS83

HCPCS84

HCPCS85

HCPCS86

HCPCS87

HCPCS88

HCPCS89

HCPCS90

HCPCS91

HCPCS92

HCPCS93

HCPCS94

HCPCS95

HCPCS96

HCPCS97

HCPCS98

HCPCS99

HCPCS100

HCPCS101

HCPCS102

HCPCS103

HCPCS104

HCPCS105

HCPCS106

HCPCS107

HCPCS108

HCPCS109

HCPCS110

HCPCS111

HCPCS112

HCPCS113

HCPCS114

HCPCS115

HCPCS116

HCPCS117

HCPCS118

HCPCS119

HCPCS120

HCPCS121

HCPCS122

HCPCS123

HCPCS124

HCPCS125

HCPCS126

HCPCS127

HCPCS128

HCPCS129

HCPCS130

HCPCS131

HCPCS132

HCPCS133

HCPCS134

HCPCS135

HCPCS136

HCPCS137

HCPCS138

HCPCS139

HCPCS140

HCPCS141

HCPCS142

HCPCS143

HCPCS144

HCPCS145

HCPCS146

HCPCS147

HCPCS148

HCPCS149

HCPCS150

HCPCS151

HCPCS152

HCPCS153

HCPCS154

HCPCS155

HCPCS156

HCPCS157

HCPCS158

HCPCS159

HCPCS160

HCPCS161

HCPCS162

HCPCS163

HCPCS164

HCPCS165

HCPCS166

HCPCS167

HCPCS168

HCPCS169

HCPCS170

HCPCS171

HCPCS172

HCPCS173

HCPCS174

HCPCS175

HCPCS176

HCPCS177

HCPCS178

HCPCS179

HCPCS180

HCPCS181

HCPCS182

HCPCS183

HCPCS184

HCPCS185

HCPCS186

HCPCS187

HCPCS188

HCPCS189

HCPCS190

HCPCS191

HCPCS192

HCPCS193

HCPCS194

HCPCS195

HCPCS196

HCPCS197

HCPCS198

HCPCS199

HCPCS200

PATIENT AGE

PATIENT AGE IN DAYS

LENGTH OF STAY

DISCHARGE STATUS

HAPGAR_1min

HAPGAR_5min

CMB1 (COMORBID: CHF)

CMB2 (VALVULAR DISEASE)

CMB3 (PULMONARY CIRC. DISEASE)

CMB4 (PERIPHERAL VASCULAR DISEASE)

CMB6 (PARALYSIS)

CMB7 (OTHER NEUROLOGICAL DISORDERS)

CMB8 (CHRONIC PULMONARY DISEASE)

CMB9 (DIABETES W/O COMPLICATIONS)

CMB10 (DIABETES W/ COMPLICATIONS)

CMB11 (HYPOTHYROIDISM)

CMB12 (RENAL FAILURE)

CMB13 (LIVER DISEASE)

CMB14 (PEPTIC ULCER DISEASE)

CMB15 (AIDS)

CMB16 (LYMPHOMA)

CMB17 (METASTATIC CANCER)

CMB18 (SOLID TUMOR W/O METASTASIS)

CMB19 (RHEUMATOID ARTHRITIS)

CMB20 (COAGULOPATHY)

CMB21 (OBESITY)

CMB22 (WEIGHT LOSS)

CMB23 (FLUID/ELECTROLYTE DISORDERS)

CMB24 (CHRONIC BLOOD LOSS/ANEMIA)

CMB25 (DEFICIENCY ANEMIAS)

CMB26 (ALCOHOL ABUSE)

CMB27 (DRUG ABUSE)

CMB28 (PSYCHOSES)

CMB29 (DEPRESSION)

NUMBER OF DIAGNOSES

CMB5 (HYPERTENSION)

NUMBER OF COMORBIDITIES

CITY

COUNTY

PRAMS Data