SITE SURVEY

Please submit a separate form for each hospital.

General Site Information

Site name
Address
Hospital system affiliation	"none" if not applicable
Hospital Medicare provider ID#
Number of beds
Teaching status
Location

Contact Information

	Physician Coordinator (Site P.I.)	Research Site Coordinator
Name (specify degree(s))
Title
Address (If different than site address)
Phone
Fax
Email
Contact preference
Primary study contact

Computer Equipment Availability

Does the research site coordinator have regular access to a computer?
Yes No

Does the research site coordinator have Internet access?
Yes No

Previous Research at Hospital

Has your hospital been involved in any cardiovascular studies or registries in the last 5 years?
Yes No

If YES, which:
NRMI
CRUSADE
ACC ACTION
ACC CathPCI
Other

If "Other", Please specify:

Does your hospital have experience identifying consecutive patients for AMI or other heart study/registry inclusion?
Yes No

Could you identify a method at your site for obtaining a daily list of patients

with positive troponin levels?
Yes No

Institutional Review Board (IRB) Information

For this study, would your hospital be willing to accept institutional review board (IRB) approval of the patient consent form and process from Yale University? Yes No

If NO, does your hospital use a central (national or regional) IRB for approval of patient studies? Yes No

IF YES, IRB Name:
Comment
IF NO, Does your hospital require approval from its own IRB? Yes No
If YES, how long does the approval process typically take?

For either a central or hospital IRB, does the IRB charge a fee?
Yes Amount No

Feasibility of Obtaining Blood Sample in Hospital
Note: The costs of blood drawing kits and shipping to a central lab will be paid by the study.

Could the research site coordinator draw a blood sample for each study patient in the hospital?
Yes No

If NO, could a site coordinator or similarly designated person at your hospital collect a blood sample at 4-6 weeks?
Yes No

Is there a fee (per patient) for obtaining the blood samples?
Yes Per patient amount No fee involved

Using the following criteria for obtaining the data,
please provide the following statistics

Data Query for Volume of Total AMI Patients

Time frame: patients discharged in calendar year 2006 (1/1/06 - 12/31/06, inclusive)
ICD-9 principal discharge diagnosis of AMI (410.xx), excluding 410.x2 (readmission for AMI)
Sort by gender

Calendar Year 2006
Total Annual AMI Volume

	Age

Women
Men
Unknown
TOTAL

Data Query for Volume of AMI Patients Age 55 and Younger

Time frame: patients discharged in calendar year 2006 (1/1/06 – 12/31/06, inclusive)
ICD-9 principal discharge diagnosis of AMI (410.xx), excluding 410.x2 (readmission for AMI)
Sort by gender and race/ethnicity (see table below)

Calendar Year 2006
Annual AMI Volume
**Patients Age 55 and Younger**

	Total Patients	Race/Ethnicity for Patients
	Total Patients	White	African- American	Hispanic	Other/ Unknown
Women
Men
Unknown
TOTAL

Name of person completing survey
Telephone