Form OTP Mortality Repo OTP Mortality Repo Attachment C - OTP Mortality Reporting Form

DEPARTMENT OF HEALTH AND HUMAN SERVICES SUBSTANCE ABUSE AND MENTAL HEALTH SERVICES ADMINISTRATION CENTER FOR SUBSTANCE ABUSE TREATMENT

Form Approved: OMB Number 0930-XXXX Expiration Date: XX/XX/XXXX See OMB Statement on Reverse

SAMHSA OTP Mortality Report

D ate of Report: ______/______/______ Follow-up report?

Note: This form will assist in the regulatory agency review of patients who die while enrolled in Opioid Treatment Programs certified to operate by SAMHSA. The goal is to improve the quality of care of these programs. Please print all information clearly.

A. Background Information

Patient’s OTP ID No.:

Program OTP No.: (Same as SAMHSA ID)

-

-

P mm dd yyyy atient’s Date of Birth: ______/______/______

Patient’s ZIP Code of Residence: __________

Patient’s Sex: Female ___ Male ___

A mm dd yyyy pproximate Date of Death: ______/______/______

Patient’s Admission Date: ______/______/______

Reporter’s Name: ___________________________________

B mm dd yyyy mm dd yyyy last name, first name mm dd yyyy . Date and Amount of Last Opioid Dose Dispensed Before Death: Last Time Dosed at Clinic: ______/______/______ Opioid: ___Methadone or ___Suboxone or ___Subutex Last Dose: _____ mgs Number of Take-Home Doses Dispensed at Last Visit: __________

C. Treatment Objective at Time of Death: ___Induction ___Maintenance ___Medically Supervised ___Other ______________________ Withdrawal (Detox)

D. Most Recent Drug Test Date: ______/______/______ Results: ___________________________________________________

E. Medical and Psychiatric Diagnosis:

F. Preliminary (P) or Confirmed (C) Underlying Cause/Mechanism of Death:

___Axis I ___Axis II ___Axis III ___Axis IV ___Axis V

For SUD:  Early Remission  Partial Remission  Full Remission  Controlled Environment

___Overdose ___Motor Vehicle Accident ___Homicide ___Suicide ___HIV/AIDS ___Cancer ___Cardiovascular ___Diabetes

___Kidney Disease ___Liver Disease ___Seizures ___Unknown/Undetermined ___Trauma ___COPD ___Other (list) _______________________ _______________________

G. List of Known OTC and Prescription Medications at the Time of Last Visit:

H. Description of Event (detailed description of the factors related to the patient’s death, including where the death occurred, if others were involved, how the death was discovered, list of illicit drugs involved, etc.). If more space is needed, use a continuation sheet, as described in the general instructions accompanying this form.

I. Other Relevant Medical History (for example, allergies, pregnancy, preexisting medical conditions):

J. Medical Examiner’s/Coroner’s Contact Information (if known):

P lease fax to CSAT/DPT at 240– 276–1630. Patient and reporter identifiers reported to SAMHSA on this form will be kept confidential by SAMHSA and will not be disseminated outside of the Federal Government.

Purpose of Form: This form will assist in the regulatory agency review of patients who die while enrolled in Opioid Treatment Programs certified to operate by SAMHSA.

Paperwork Reduction Act Statement

Public Burden Statement: An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number.  The OMB control number for this project is 0930-xxxx.  Public reporting burden for this collection of information is estimated to average .50 hours per client per year, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.  Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to SAMHSA Reports Clearance Officer, 1 Choke Cherry Road, Room 7-1044, Rockville, Maryland, 20857.