2
Form
Approved OMB
No. 0920-XXXX
Exp.
Date xx/xx/20xx
Form
Approved OMB
No. 0920-XXXX
Exp.
Date xx/xx/20xx
Form
Approved OMB
No. 0920-XXXX
Exp.
Date xx/xx/20xx
P
Form
Approved OMB
No. 0920-0852 Exp.
Date 05/31/2013
CDC ID: - Survey date: // Data collector initials: _____
I. Identifiers (for Primary Team and EIP Team use only; identifiers are not transmitted to CDC)
|
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Patient name: ___________________________________ (Last, First, MI) |
Date of birth: // |
Hospital name: __________________________________ |
Hospital unit name: ______________________________ |
Room number: __________________________________ |
Medical record no.: ______________________________
|
II. Demographics
|
|
||
Age: _______ years months days
|
Admission date: // |
||
Gender: M F Unknown |
CDC location code: __________________________
|
||
Race (check all that apply): American Indian or Alaska Native Black or African American Native Hawaiian or other Pacific Islander Asian |
White Other race Unknown
|
Ethnicity: Hispanic or Latino Not Hispanic or Latino Unknown
|
|
III. Risk factors (in place on the survey date) |
||
Urinary catheter: |
No Yes Unknown
|
|
Ventilator: |
No Yes Unknown
|
|
Central line: |
No Yes
Unknown |
If “Yes,” check all that apply:
PICC Femoral line Other central line Unknown
|
IV. Antimicrobials |
|
On antimicrobials on the survey date or the calendar day prior to the survey date: |
No Yes Unknown |
**Qualification for hemodialysis and peritoneal dialysis patients ONLY**
On any of the following antimicrobials in the 4 calendar days prior to the survey date: vancomycin, amikacin, gentamicin, tobramycin, streptomycin, kanamycin
|
NA, not a dialysis patient
No Yes Unknown |
FORM IS COMPLETE
Public
reporting burden of this collection of information is estimated to
average
7 minutes
per response, including the time for reviewing instructions,
searching existing data sources, gathering and maintaining the data
needed, and completing and reviewing the collection of information.
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. Send comments regarding this
burden estimate or any other aspect of this collection of
information, including suggestions for reducing this burden to
CDC/ATSDR Reports Clearance Officer, 1600 Clifton Road NE, MS D-74,
Atlanta, Georgia 30333; ATTN: PRA 0920-0852.
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Phase 3_DCF_v1_20101210 page 1 of 1
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Shelley Magill |
| File Modified | 0000-00-00 |
| File Created | 2021-01-28 |