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pdf– ACTIVE BACTERIAL CORE SURVEILLANCE CASE REPORT –
Patient's Name:
Phone No.:(
Patient
Chart No.:
(Last, First, M.I.)
Address:
)
(Number, Street, Apt. No.)
Hospital:
(Zip Code)
(City, State)
– Patient identifier information is not transmitted to CDC –
DEPARTMENT OF
HEALTH & HUMAN SERVICES
CENTERS FOR DISEASE CONTROL
AND PREVENTION
ATLANTA, GA 30333
ACTIVE BACTERIAL CORE
SURVEILLANCE (ABCs) CASE REPORT
A CORE COMPONENT OF THE EMERGING INFECTIONS PROGRAM NETWORK
OMB No. 0920-0009
– SHADED AREAS FOR OFFICE USE ONLY –
1. STATE:
(Residence
of Patient)
2. COUNTY:
(Residence of Patient)
5. WAS PATIENT
HOSPITALIZED?
If YES, date of admission:
Mo.
1
Yes
2
3. STATE I.D.:
Day
Yes 2
4b. HOSPITAL I.D. WHERE
PATIENT TREATED:
6a. Was patient transferred
from another hospital?
6b. If YES, hospital I.D.
Date of discharge:
Year
Mo.
Day
Year
1
No
7a. Was patient a resident of a nursing home or other
chronic care facility at the time of first positive culture?
1
4a. HOSPITAL /LAB I.D. WHERE
CULTURE IDENTIFIED:
No 9
Yes 2
Mo.
Unk
9b. Is age in day/mo/yr?
9a. AGE:
8. DATE OF BIRTH:
Unk
No 9
Day
Year
1
7b. If yes, name _____________________________________
10. SEX:
11a. ETHNIC ORIGIN:
1
Male
2
Female
1
2
9
Hispanic or Latino
Not Hispanic or Latino
Unk
White
1
Black
1
American Indian
1
or Alaska Native
________ lbs ________ oz OR ________ kg
1
Asian
1
Native Hawaiian
or Other Pacific Islander 12b. HEIGHT:
Unk
________ ft ________ in OR ________ cm
13. TYPE OF INSURANCE: (check all that apply)
1
Medicare
1
Indian Health Service (IHS)
1
No health care coverage
Military/VA
1
Private/HMO/PPO/managed care plan
1
Unk
1
Medicaid/state assistance program
1
Other (specify) ______________________________________________
1
Pregnant
3
Neither
2
Post-partum
9
Unk
1
Sur vived, no apparent illness
3
Live bir th/neonatal death 5
Induced abor tion
2
Sur vived, clinical infection
4
Abor tion/stillbir th
Unk
1
1
Peritonitis
1
Endometritis
1
Meningitis
1
Pericarditis
1
STSS
1
Otitis media
1
Septic abortion
1
Necrotizing fasciitis
1
Pneumonia
1
Chorioamnionitis
1
Puerperal sepsis
1
Cellulitis
1
Septic ar thritis
1
Other (specify)
1
1
Osteomyelitis
1
Epiglottitis
Hemolytic uremic
syndrome (HUS)
1
Empyema
1
Abscess (not skin)
1
Endocarditis
1
Unk
19. STERILE SITES FROM WHICH ORGANISM ISOLATED: (Check all that apply)
1
Blood
1
Peritoneal fluid
1
Bone
1
CSF
1
Pericardial fluid
1
Muscle
1
Unk
1
Survived
2
Died
9
Unk
9
Gestational
age:
Birthweight:
(wks)
Bacteremia
without Focus
Pleural fluid
Unk
16. If p atient <1 month of age:
15b. If pregnant or post-partum, what was the outcome of fetus:
17. TYPES OF INFECTION CAUSED BY ORGANISM: (Check all that apply)
1
Yrs.
14. OUTCOME:
1
15a. At time of first positive culture,
patient was:
Mos. 3
12a. WEIGHT:
11b. RACE: (Check all that apply)
1
Days 2
18a. BACTERIAL SPECIES ISOLATED FROM ANY NORMALLY STERILE SITE:
1
Neisseria meningitidis
4
Listeria monocytogenes
2
Haemophilus influenzae
5
Group A streptococcus
3
Group B streptococcus
6
Streptococcus pneumoniae
18b. OTHER BACTERIAL SPECIES ISOLATED FROM ANY NORMALLY
STERILE SITE: (specify)
20. DATE FIRST POSITIVE
CULTURE OBTAINED:
(Date Specimen Drawn)
Mo.
Joint
(gms)
Day
Year
21. OTHER SITES FROM WHICH ORGANISM
ISOLATED: (Check all that apply)
1
Placenta
1
Middle ear
1
Amniotic fluid
1
Sinus
1
Internal body site (specify) ________________________________________________________
1
Wound
1
Other normally sterile site (specify) ___________________________________
1
Other (specify) _________________
Public reporting burden of this collection of information is estimated to average 10 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, CDC/ATSDR Reports Clearance Officer,
1600 Clifton Road, MS D-74, Atlanta, GA 30333, ATTN: PRA (0920-0009). Do not send the completed form to this address.
CDC 52.15A
RE V. 12-2007
– ACTIVE BACTERIAL CORE SURVEILLANCE CASE REPORT –
– IMPORTANT – PLEASE COMPLETE THE BACK OF THIS FORM –
Page 1 of 2
22. UNDERLYING CAUSES OR PRIOR ILLNESS:
(Check all that apply)
(If none or chart unavailable, check appropriate box) 1
None
1
Unknown
1
Current Smoker
1
Asthma
1
Cirrhosis/Liver Failure
1
Cochlear Implant
1
Multiple Myeloma
1
Emphysema/COPD
1
1
Deaf/Profound Hearing Loss
1
Sickle Cell Anemia
1
1
1
Splenectomy/Asplenia
Systemic Lupus
Erythematosus (SLE)
1
Immunoglobulin Deficiency
1
Diabetes Mellitus
1
1
Immunosuppressive Therapy
(Steroids, Chemotherapy, Radiation) 1
Nephrotic Syndrome
1
1
Alcohol Abuse
Atherosclerotic Cardiovascular
Disease (ASCVD)/CAD
Heart Failure/CHF
1
Leukemia
1
HIV Infection
1
Hodgkin's Disease
1
AIDS or CD4 count <200
Renal Failure/Dialysis
_____________________________________
Organ Transplant (specify)
1
Obesity
CSF Leak
IVDU
Cerebral Vascular Accident (CVA) / Stroke
Complement Deficiency
1
1
1
1
Other Malignancy (specify)
1
_____________________________________
1
Other Prior Illness (specify)
_____________________________________
_____________________________________
– IMPORTANT – PLEASE COMPLETE FOR THE RELEVANT ORGANISMS:
HAEMOPHILUS
INFLUENZAE
23b. Were records obtained to verify
vaccination history? (<5 years of age only)
23 a. If <15 years of age and serotype ‘b’ or ‘unk’ did
1
Yes 2
No
9
Unk
patient receive Haemophilus influenzae b vaccine?
If YES, please complete the list below.
DATE GIVEN
LOT NUMBER
MANUFACTURER
VACCINE NAME
DOSE
Mo.
Day
1
Year
1
2
3
4
___________________
_________________________________________________
___________________
1
Vaccine Registry
_________________________________________________
___________________
1
Healthcare Provider
_________________________________________________
___________________
1
Other (specify) _______________________
3
a
4
c
5
d
6
e
7
Other (specify) _______________________
8
f
A
3
C
5
W135
9
Unk
2
B
4
Y
6
Not groupable
8
Other (specify) ___________________________________________
1
2
No
9
Not Tested or Unk
Yes 2
No 9
DATE GIVEN
List most recent date for each vaccine
VACCINE NAME/MANUFACTURER
Mo.
Yes
9
26. Is patient currently attending college?
(15 – 24 years only)
25. What was the serogroup?
1
27. Did patient receive meningococcal vaccine?
1
No
_________________________________________________
24. What was the serotype?
1
b
2
Not Typeable
NEISSERIA MENINGITIDIS
Yes 2
If yes, what was the source of the
information? (check all that apply)
Day
If YES, please complete the following information:
_______________
Menactra, tetravalent meningococcal conjugate vaccine
_______________
Other (specify)___________________________________
_______________
Not Known
Yes
2
No
9
DATE GIVEN
Mo.
28. If <15 years of age did patient receive
pneumococcal conjugate vaccine?
1
_______________
DOSE
STREPTOCOCCUS PNEUMONIAE
Day
VACCINE NAME/MANUFACTURER
Year
1
2
Unk
If YES, please complete the following information:
3
4
GROUP A STREPTOCOCCUS
(#29–31 refer to the 7 days
prior to first positive culture)
29. Did the patient have surgery ? 1
If YES,
date of surgery:
Yes
Mo.
2
Day
No
9
LOT NUMBER
Year
Menomune, tetravalent meningococcal polysaccharide vaccine
Unk
Unk
Unk
Year
_____________________________________________________
_______________
_____________________________________________________
_______________
_____________________________________________________
_______________
_____________________________________________________
_______________
30. Did the patient deliver a baby
(vaginal or C-section)?
1
Yes 2
No 9
If YES,
date of delivery:
LOT NUMBER
Mo.
31. Did patient have:
Unk
Day
Year
1
Varicella
1
Penetrating trauma
1
Blunt trauma
1
Surgical wound
(post operative)
1
Burns
32. COMMENTS:
– SURVEILLANCE OFFICE USE ONLY –
33. Was case first
identified through
audit?
1
Yes
2
9
Unk
No
34. CRF Status:
1
2
3
4
Complete
Incomplete
Edited & Correct
Chart unavailable
after 3 requests
35. Does this case have
recurrent disease with
the same pathogen?
1
Yes
9
Unk
2
36. Date reported to EIP site
If YES, previous
(1st) state I.D.
Mo.
No
Submitted By:
Phone No.: (
)
Physician’s Name:
Phone No.:(
)
CDC 52.15A
REV. 12-2007
– ACTIVE BACTERIAL CORE SURVEILLANCE CASE REPORT –
Day
37. Initials
of S.O.
Year
Date:
Page 2 of 2
| File Type | application/pdf |
| File Title | CDC 52.15A |
| Author | bjb1 |
| File Modified | 2008-07-10 |
| File Created | 2007-12-20 |