This form is provided as a template to aid CRANE data collection. The data recorded on this form MUST be transferred to the CRANE electronic database. Paper forms cannot be accepted for entry.
1. Patient Registration
Note: This section is used to collect basic patient information for cleft patients. It is required for each new patient.
Cleft team details
Administrative centre hospital No.
______________________________
Local (spoke) hospital name
______________________________
Local (spoke) hospital No.
______________________________
Patient details
CRANE ID ____________________
Automatically generated by CRANE Database
Patient’s NHS Number
Date of birth
Present surname
/ / (DD / MM / YYYY)
__________________________________
First names
Postcode
__________________________________
Surname at birth (if different)
__________________________________
See DATA COLLECTION FORM 1 for:
Section 2. Cleft Details, Section 3. Surgical Procedures and Section 4.1 & 4.2 Outcomes at Birth & at 1 year
Outcomes at 5 years can be collected on the next 2 pages
Page 1 of 3
Date of release 18/07/2014 (Version 4)

4. Outcomes
4.3 Outcome at 5 years
Note: This section is used to add outcome records.
Nursing (all cleft types)
Weight at 5 years
Height at 5 years
.
.
(kg)
(cm)
Reason for exclusion from audit
Patient deceased or emigrated
Patient transferred out of area
Clinically contraindicated
(this record type for this patient)
Other reason.
Please detail reason
___________________________
Confirmed syndromic diagnosis present
No
Yes, named syndrome. Please specify syndrome name(s) ______________________
Yes, unknown syndromic diagnosis.
Please describe affected systems__________________________________________
Reason audit record not available
Patient not seen: Lack of staff or facilities
Patient not seen: No appointment made, or defaulted once & no further apt made
Patient not seen: Multiple appointments defaulted (DNA or patient cancelled)
Patient seen: Not possible to take record due to lack of consent and/or
patient cooperation
Patient seen: Not possible to take record for reasons unrelated to the patient
Patient seen: Record taken but not available for audit
Other reason. Please detail reason ________________________________________
Paediatric Dentistry (all cleft types)
Record taken / / (DD / MM / YYYY)
Total number of decayed, missing or filled teeth in primary dentition (dmft)
(if none, specify 0)
Total number of decayed teeth in primary dentition (dt)
(if none, specify 0)
Total number of missing teeth in primary dentition (mt)
(if none, specify 0)
Reason for exclusion from audit
Patient deceased or emigrated
Patient transferred out of area
Clinically contraindicated
(this record type for this patient)
Other reason.
Please detail reason
___________________________
Total number of filled teeth in primary dentition (ft)
(if none, specify 0)
Reason audit record not available
Patient not seen: Lack of staff or facilities
Patient not seen: No appointment made, or defaulted once & no further apt made
Patient not seen: Multiple appointments defaulted (DNA or patient cancelled)
Patient seen: Not possible to take record due to lack of consent and/or
patient cooperation
Patient seen: Not possible to take record for reasons unrelated to the patient
Patient seen: Record taken but not available for audit
Other reason. Please detail reason ________________________________________
Page 2 of 3
Date of release 18/07/2014 (Version 4)

Orthodontics (UCLP cases only)
Date study model taken / / (DD / MM / YYYY) Date photos taken / / (DD / MM / YYYY)
Five Year Old Index (Internally validated score) _____________
Reason for exclusion from audit
Patient deceased or emigrated
Five Year Old Index (Externally validated score) _____________
Reason audit record not available
Patient not seen: Lack of staff or facilities
Patient not seen: No appointment made, or defaulted once & no further apt made
Patient not seen: Multiple appointments defaulted (DNA or patient cancelled)
Patient transferred out of area
Clinically contraindicated
(this record type for this patient)
Other reason.
Please detail reason
___________________________
Patient seen: Not possible to take record due to lack of consent and/or
patient cooperation
Patient seen: Not possible to take record for reasons unrelated to the patient
Patient seen: Record taken but not available for audit
Other reason. Please detail reason ________________________________________
Speech and Language Therapy: CAPS-A
Date of Speech Audit Recording / / (DD / MM / YYYY) VP surgery / Fistula repair before Audit? Yes No
Consensus Listened (includes an external CAPS-A trained listener)
Context of Evaluation Consensus Listened (internal listeners with a minimum of 2 CAPS-A trained listeners)
Other
Hypernasality
Hyponasality
Anterior Cleft Speech
Characteristics (CSCs)
Audible Nasal Emission
Nasal Turbulence
0
0
1
1
Scoring for each of the Summary Categories of Cleft Speech Characteristics (CSCs) – definitions:
2
2
8
8
A Dark Green on CAPS-A
C Amber on CAPS-A
B Light Green on CAPS-A
D Red on CAPS-A
1.
Dentalisation / Interdentalisation
2.
Lateralisation / Lateral
0 1 2 3 4 8
0 1 2 8
A B
A B C
3.
Palatalisation / Palatal A B C
Posterior CSCs
Non Oral CSCs
4.
Double articulation (posterior)
5.
Backed to velar / Uvular
6.
Pharyngeal articulation
7.
Glottal Articulation
A B C
A C D
A C D
A C D
Passive CSCs
8.
Active Nasal Fricatives
9.
Double articulation (non-oral)
10.
Weak and or nasalised consonants
A C D
A C D
A C D
11.
Nasal realisation of plosives
12.
Gliding of fricatives
Reason for exclusion from audit
Patient deceased or emigrated
Patient transferred out of area
Clinically contraindicated
(this record type for this patient)
Other reason.
Please detail reason
___________________________
A
A
C
C
D
D
Reason audit record not available
Patient not seen: Lack of staff or facilities
Patient not seen: No appointment made, or defaulted once & no further apt made
Patient not seen: Multiple appointments defaulted (DNA or patient cancelled)
Patient seen: Not possible to take record due to lack of consent and/or
patient cooperation
Patient seen: Not possible to take record for reasons unrelated to the patient
Patient seen: Record taken but not available for audit
Other reason. Please detail reason ________________________________________
End of DATA COLLECTION FORM 2
Page 3 of 3
Date of release 18/07/2014 (Version 4)