The code block below illustrates how one might use # and // as comments in your logic and calculations.

This value you provided is not a number. Please try again.

This value you provided is not an integer. Please try again.

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

The value you provided is outside the suggested range

This value is admissible, but you may wish to double check it.

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.

This field must be a 10 digit U.S. phone number (like 415 555 1212). Please re-enter it now.

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The value you provided could not be validated because it does not follow the expected format. Please try again.

Required format:

DCUILAwrIfqznrI4d8nYMBuUppWuQQdVpSwMnxnHgnSPPIBacmGqIgah3Ux6RKknp3Wkewa3y53ZXB24WyA4o4SqR9oced

Notification Form

This data collection form was created by the Barbados National Registry for Chronic Non-communicable Diseases (BNR) using REDCap software.

REDCap is a secure web application for building and managing online surveys and databases. While REDCap can be used to collect virtually any type of data in any environment (including compliance with 21 CFR Part 11, FISMA, HIPAA, and GDPR), it is specifically geared to support online and offline data capture for research studies and operations.

REDCap is operated through the GA-CDRC and hosted in a HIPAA compliant and GDPR compliant environment.

Please complete the info below.

Thank you!

Notification Date

* must provide value

D-M-Y

Physician Address/Clinic Name

* must provide value

Physician Name

* must provide value

Patient First Name

* must provide value

Patient Last Name

* must provide value

National Registration Number

* must provide value

Date of Birth

* must provide value

D-M-Y

Age

* must provide value

Gender

* must provide value

Female

Male

reset

Date of patient's first visit for this event

* must provide value

D-M-Y

What type of event are you notifying?

* must provide value

Stroke Notification - Event Date

* must provide value

D-M-Y

Presenting Complaints

* must provide value

facial weakness

weakness in arm or leg

difficulty speaking or understanding speech

dizziness/loss of coordination

loss of consciousness

Heart Notification - Event Date

* must provide value

D-M-Y

Presenting Complaints

* must provide value

chest pain

sweating

shortness of breath

nausea

Referred to Hospital?

* must provide value

Yes

reset

Cancer Notification - Diagnosis Date

* must provide value

D-M-Y

Site

* must provide value

Diagnosis

How was the patient diagnosed?

* must provide value

Death Certificate Only

Clinical only

Clinical Invest./Ult Sound

Exploratory Surgery/Autopsy

Laboratory test (biochemical/immunological)

Cytology/Haematology

Histology of metastases

Histology of primary

Autopsy with Histology

Unknown

reset

Type of Diagnostic Report

CT brain

ECG

Chest X-ray

MRI brain

Angiography (cerebral)

Angiography (carotid)

Carotid Ultrasound

ECHO (transthoracic echo)

CT/coronary Angiography

Stress test/treadmill

TEE (transoesophageal echocardiography)

Lumbar Puncture

Pathology

Cytology

Haematology

Imaging

Death Certificate/Post Mortem

Other

Unknown

Please upload diagnostic report

Upload file

Please include any relevant documentation to assist with case finding.
This can include records from:

CT brain

ECG

chest x-ray

MRI brain

angiography (cerebral)

angiography (carotid)

carotid ultrasound

ECHO (transthoracic echo)

CT/coronary angiography

stress test/treadmill

any other exams/interventions include e.g. TEE (transoesophageal echocardiography), lumbar puncture

Pathology

Cytology

Haematology

Imaging

Death Certificate/Post Mortem

Status at last contact

* must provide value

Dead

Alive

Unknown

reset

Date of last contact or date of death

* must provide value

D-M-Y

Has this been imported into CVDdb and/or Cancer db?

Yes No

reset

Mark field as:

[Clear value]

ND / date ND / NK / Unknown / No record of use (99)

You have selected an option that triggers this survey to end right now.

To save your responses and end the survey, click the 'End Survey' button below. If you have selected the wrong option by accident and/or wish to return to the survey, click the 'Return and Edit Response' button.