1) Orientation Month: 0 1

Date: 0 1

Day of week: 0 1

Year: 0 1

Time (within 1 hr.): 0 1

Orientation Total Score /5

2) Immediate Memory: (all 3 trials are completed regardless of score on trial 1 & 2; total score equals sum across all 3 trials)

List Trial 1 Trial 2 Trial 3

Word 1 0 1 0 1 0 1 Word 2 0 1 0 1 0 1 Word 3 0 1 0 1 0 1 Word 4 0 1 0 1 0 1 Word 5 0 1 0 1 0 1 Total Immediate Memory Total Score/ 15

(Note: Subject is not informed of Delayed Recall testing of memory)

NEUROLOGICAL SCREENING:

Loss of Consciousness: (occurrence, duration)

Retrograde and & Posttraumatic Amnesia: (recall of events pre- and post-injury)

Strength:

Sensation:

Coordination:

3)Concentration:

Digits Backward (If correct, go to next string length. If incorrect, read trial 2. Stop after incorrect on both trials)

4-9-3 6-2-9 _0 1 3-8-1-4 3-2-7-9 _0 1 6-2-9-7-1 1-5-2-8-6 _0 1 7-1-8-4-6-2 5-3-9-1-4-8 _0 1 Months in reverse order: (entire sequence correct for 1 point) Dec-Nov-Oct-Sep-Aug-Jul Jun-May-Apr-Mar-Feb-Jan_0 1

Concentration Total Score/ 5

Exertional Maneuvers (when appropriate):

5 jumping jacks 5 push-ups 5 sit-ups 5 knee-bends

4) Delayed Recall

Word 101 Word 201 Word 301 Word 401 Word 501

Delayed Recall Total Score / 5 Summary of Total Scores: Orientation_/ 5 Immediate Memory_/ 1 Concentration_/ 5 Delayed Recall_/ 5

Overall Total Score___/30

http://www.cdc.gov/ncipc/pub-res/tbi_toolkit/mccrae/results.htm