2008 Active Bacterial Core Surveillance Case Report Form

– ACTIVE BACTERIAL CORE SURVEILLANCE CASE REPORT –

Phone No .: (
Patient
Chart No.:

Patient's Name:
(Last, First, M.I.)

Address:

)

(Number, Street, Apt. No.)

Hospital:

(Zip Code)

(City, State)

– Patient identifier information is not transmitted to CDC –

A CTIVE B ACTERIAL C ORE
SURVEILLANCE (ABCs) CASE REPORT

DEPARTMENT OF
HEALTH & HUMAN SERVICES
CENTERS FOR DISEASE CONTROL
AND PREVENTION
ATLANTA, GA 30333

A CORE COMPONENT OF THE EMERGING INFECTIONS PROGRAM NETWORK
OMB No. 0920-0802

– 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

3. STATE I.D.:

2

Day

Date of discharge:

Year

Mo.

Yes 2

4b. HOSPITAL I.D. WHERE
PA TIENT TREATED:

6a. Was patient transferred
from another hospital?

6b. If YES, hospital I.D.

Year

1

No

7a. Was patient a resident of a nursing home or other
chr onic care facility at the time of first positive culture?
1

Day

4a. HOSPITAL /LAB I.D. WHERE
CULTURE IDENTIFIED:

Mo.

Unknown

No 9

9b. Is age in day/mo/yr?

9a. AGE:

8. DATE OF BIRTH:

Unknown

No 9

Yes 2

Day

Year

1

Days 2

Mos. 3

Yrs.

7b. If yes, name _____________________________________
10. SEX:

11a . ETHNIC ORIGIN:

1

Male

2

Female

1
2
9

12a. WEIGHT:

11b. R ACE: (Check all that apply)

Hispanic or Latino
Not Hispanic or Latino
Unknown

1

White

1

Black

1

American Indian
1
or Alaska Native

1
1

__ ____ __ lbs _____ ___ oz OR

Asian
Native Hawaiian
or Other Pacific Islander
Unknown

__ ____ __ ft _____ ___ in OR

1

Medicare

1

Indian Health Service (IHS)

1

No health care coverage

Mil itary/VA

1

Private/HMO/PPO/managed care plan

1

Unknown

1

Medicaid/state assistance program

Pregnant

2

Post-partum

3
9

17. TYPES OF INFECTION C

1

1

Survived, no apparent illness

3

Live bi rth/neonatal death

5

Induced abortion

2

Survived, clinical infection

4

Abortion/stillbirth

9

Unknown

Neither

Survived

2

Died

Gestational
age:

Unknown

9

Unknown

Birthweight:

(wks)
(Che ck all that apply)

1

1

Per itonitis

1

Endometritis

1

Meningitis

1

Per icarditis

1

STSS

1

Otitis media

1

Septic abortion

1

Necrotizing fasciitis

1

Pneumonia

1

Chorioamnionitis

1

Puerperal sepsis

1

Cellulitis

1

Septic a rthritis

1

1

Osteomyelitis

1

Epiglottitis
Hemolytic uremic
syndrome (HUS)

1

Empyema

1

Abscess (not skin)

1

Endocarditis

1

Other (specify)

1

Unknown

19. STERILE SITES FR OM WHICH ORGANISM ISOLATED: (Check all that apply)
1

Blood

1

Per itoneal fluid

1

Bone

1

CSF

1

Per icardial fluid

1

Muscle

1

1

16. If patient <1 month of age

15b. If pregnant or post-partum, what was the outcome of fetus:

Bacteremia
without Focus

Pleural fluid

Unknown

Other (specify)

AUSED BY ORGANISM:

1

____ ___ _ cm
14. OUTCOME:

1

15a. At time of first positive culture,
patient was:

Unknown

12b. HEIGHT:

13. TYPE OF INSURANCE: (check all that apply)

1

__ ___ ___ kg

18a. B ACTERIAL SPECIES ISOL

ATED F R OM ANY NORMAL

LY STERILE SITE:

1

Neisseria meningitidis

4

Listeria monocytogenes

2

Haemophilus influenzae

5

Group A s treptococcus

3

Group B s treptococcus

6

Streptococcus pneumoniae

18b. OTHER BACTERIAL SPECIES ISOLATED F ROM ANY NORMALLY
STERILE SITE: (specify)

20 . DATE FIRST POSITIVE
CULTURE OBTAINED:

21. OTHER SITES F R OM WHICH ORGANISM
ISOLATED:
(Check all that apply)

(Date Specimen Drawn)
Mo.

Joint

(gms)

Day

Year

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 (0920-0802). Do not send the completed form to this address.
CDC 52.15A RE V. 12-200 7

– ACTIVE BACTERIAL CORE SURVEILLANCE CASE REPORT –

– IMPORTANT

– PLEASE COMPLETE THE BACK OF THIS FORM –

Page 1 of 2

22. UNDER LYING CAUSES OR PRIOR ILLNESS:

(Che ck all that apply)

(If none or chart unavailable, check appropriate box)

1

None 1

Unknown

Cochlear Implant

1

Current Smoker

1

Asthma

1

Cirrhosis/Liver Failure

1

1

Multiple Myeloma

1

Emphysema/COPD

1

1

Deaf/Profound Hearing Loss

1

Sickle Cell Anemia

1

1

1

Other Malignancy (specify)

1

Splenectomy/Asplenia

Systemic Lupus
Erythematosus (SLE)

1

Immunoglobulin Deficiency

1

Diabetes Mellitus

1

Nephrotic Syndrome

1
1

Alcohol Abuse
Atherosclerotic Cardiovascular
Disease (ASCVD)/CAD
Heart Failure/CHF

1

Renal Failure/Dialysis

1

Immunosuppressive Therapy
(Steroids, Chemotherapy, Radiation)

1

Leukemia

1

HIV Infection

1

Hodgkin's Disease

1

AIDS or CD4 count <200

– IMPORTANT
HAEMOPHILUS
INFLUENZAE
DOSE
Mo.

_____________________________________

Obesity
CSF Leak
IVDU
Cereb ral Vascular Accident (CVA) / Stroke
Compl ement Deficiency

1
1
1
1

_____________________________________
1
Other Prior Illness (specify)
_____________________________________
_____________________________________

– PLEASE COMPLETE FOR THE RELEVANT ORGANISMS:
23b. Were records obtained to verify
(<5 years of age only)
vaccination history?

23 a. If <15 yea rs of age and serotype ‘b’ or ‘unk’ did
1
Yes 2
No 9
Unknown
patient receive Haemophilus influenzae b vaccine?
If YES, please complete the list below.
DATE GIVEN
MANUFACTURER
LOT NUMBER
VACCINE NAME

Day

1

Year

1
2
3
4

_________________________________________________

___________________

_________________________________________________

___________________

_________________________________________________
_________________________________________________

24. What was the serotype?
1
b
2
Not Typeable

3

NEISSERIA MENINGITIDIS

a

4

c

5

d

6

e

7

___________________

1

Healthcare Provider

___________________

1

Other (specify)

C

5

W135

9

Unknown

2

B

4

Y

6

Not groupable

8

Other (specify) ___________________________________________

1

9

Unknown

Not Tested or Unknown

9

Yes 2

No 9

DATE GIVEN
List most recent date for each vaccine

VACCINE NAME/MANUFACTURER

Mo.

No

_______________________

26. Is patient currently attending college?
(15 – 24 years only)

25. What was the serog roup?

3

2

No

Vaccine Registry

A

Yes

2

Other(specify) _______________________

8

f

Yes

If yes, what was the source of the
information? (check all that apply)
1

1

27. Did patient receive meningococcal vaccine?

1

Organ Transplant (specify)

1

Day

LOT NUMBER

Year

Menomune, tetravalent meningococcal polysaccharide vaccine

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 yea rs of age did patient receive
pneumococcal conjugate vaccine?
1

_______________

DOSE

STREPTOCOCCUS PNEUMONIAE

Day

V ACCINE NAME/MANUFACTURER

Year

1
2

Unknown

3

If YES, please complete the following information:

4
(# 29 –3 1 re fer to the 7 days
prior to first positive culture)

GROUP A STREPTOCOCCUS
29. Did the patient have surgery ? 1

Yes
Mo.

2

No
Day

9

Unknown

_____________________________________________________

_______________

_____________________________________________________

_______________

_____________________________________________________

_______________

_____________________________________________________

_______________

30. Did the patient deliver a baby
(vaginal or C-section)?

Unknown

1

Yes 2

No

Year

9

31. Did patient h ave:

Unknown
Mo.

If YES,
date of surgery:

LOT NUMBER

Day

Year

If YES,
date of delivery:

1

1

Varicella

1

Penetrating trauma

1

Blunt trauma

1

Surgical wound
(post operative)

Burns

32. COMMENTS:

– SURVEILLANCE OFFICE USE ONLY –
33. Was case first
identified through
audit?
1

Yes

2

9

Unknown

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

2

9

Unknown

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:

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