* required for saving
*Facility ID #: ____________ *Event #: _____________
*Patient ID #: _____________ Social Security #: ___ ___ ___ - ___ ___ - ___ ___ ___ ___
Secondary ID #: __________
Patient Name, Last: _______________________ First: ___________________ Middle: __________
*Gender: ___ F ___ M *Date of Birth: ____ / ____ / ______ (mm/dd/yyyy)
Ethnicity: (Specify) ______________ Race: (Specify)_______________
*Event Type: CLIP *Location: ______________ *Insertion Date: ____ / ____ / ______ (mm/dd/yyyy)
*Person recording insertion practice data: ___ Inserter ___Observer
Central line inserter ID: ___________ Name: Last____________________ First_________________
*Occupation of inserter: ___Attending physician ___ Intern/Resident ___Physician assistant ___ IV team
___Fellow ___Other medical staff ___Medical student ___ Other student
___Other (specify) ________________
*Reason for insertion: ___ New indication for central line
___ Replace malfunctioning central line
___ Suspected central line-associated infection ____ Other (specify) ___________
*Inserter performed hand hygiene prior to central line insertion: __ Y __ N
*Maximal sterile barrier precautions used: Mask/Eye shield __ Y __ N
Sterile gown __ Y __ N
Large sterile drape __ Y __ N
Sterile gloves __ Y __ N
Cap __ Y __ N
*Skin preparation (check all that apply): ___ Chlorhexidine gluconate ___ Povidone iodine ___ Alcohol
*Was skin preparation agent completely dry at the time of first skin puncture? __Y __N
*Insertion site: ___ Jugular ___ Subclavian ___ Umbilical ___ Femoral ___ Upper extremity (PICC)
Antimicrobial coated catheter used: __ Y __ N
*Central line catheter type: ___ Non-tunneled (other than dialysis) ___ Umbilical
___ Tunneled (other than dialysis) ___ PICC
___ Dialysis non-tunneled ___ Other (specify)____________
___ Dialysis tunneled
*Number of lumens (circle one): 1 2 3 ≥ 4
*Central line exchanged over a guidewire: __ Y __ N
*Antiseptic ointment applied to site: __ Y __ N
