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– ACTIVE BACTERIAL CORE SURVEILLANCE CASE REPORT –
Patient’s Name:
Phone No.: (
)
Patient
Chart No.:
(Last, First, MI.)
Address:
(Number, Street, Apt. No.)
(City, State)
– Patient identifier information is not transmitted to CDC –
DEPARTMENT OF
HEALTH AND HUMAN SERVICES
CENTERS FOR DISEASE CONTROL
AND PREVENTION
ATLANTA, GA 30333
1. STATE:
(Residence of Patient)
Yes
Active Bacterial Core
Surveillance (ABCs) CASE REPORT
3. STATE I.D.:
2. COUNTY:
(Residence of Patient)
Mo.
Day
4a. HOSPITAL/LAB I.D. WHERE
CULTURE IDENTIFIED:
Date of discharge:
Year
Mo.
Day
1
1
Private residence
4
Homeless
6
College dormitory
2
Long term care facility
5
Incarcerated
9
Unknown
3
Long term acute care facility
10a. AGE:
9. DATE OF BIRTH:
Day
10b. Is age in day/mo/yr?
1
Days 2
Mos. 3
13a. WEIGHT:
______lbs______ oz OR ______ kg
OR
13b. HEIGHT:
15. OUTCOME:
1
Survived 2
Unknown
Died 9
1
Pregnant
3
Neither
2
Postpartum
9
Unknown
1
Male
1
Hispanic or Latino
2
Female
2
Not Hispanic or Latino
9
Unknown
Bacteremia
without Focus
1
Yes 2
No
9
Unknown
1
White
1
Black
Asian
1
Native Hawaiian
or Other Pacific Islander
1
American Indian
or Alaska Native 1
1
Unknown
Medicare
1
Indian Health Service (IHS)
1
No health care coverage
Military/VA
1
Private/HMO/PPO/managed care plan
1
Unknown
1
Medicaid/state assistance program
1
Other (specify) ___________________________________________
16. If patient died, was the culture obtained on autopsy?
Unknown
1
Survived, no apparent illness 4
Abortion/stillbirth
2
Survived, clinical infection
5
Induced abortion
3
Live birth/neonatal death
6
Still pregnant
9
1
Yes
2
No
9
Unknown
18. If patient <1 month of age, indicate gestational age
and birth weight. If pregnant, indicate gestational
age of fetus, only.
Birth weight:
Gestational age:
Unknown
(wks)
(gms)
20a. BACTERIAL SPECIES ISOLATED FROM ANY NORMALLY STERILE SITE:
Peritonitis
1
Endometritis
1
Pericarditis
1
STSS
Otitis media
1
Septic abortion
1
Necrotizing fasciitis
1
Pneumonia
1
Chorioamnionitis
1
Puerperal sepsis
1
Cellulitis
1
Septic arthritis
1
Septic shock
1
Epiglottitis
1
Osteomyelitis
1
1
Hemolytic uremic
syndrome (HUS)
Other (specify)
1
Empyema
1
Abscess (not skin)
1
Endocarditis
1
Unknown
1
Neisseria meningitidis
4
Listeria monocytogenes
2
Haemophilus influenzae
5
Group A Streptococcus
3
Group B Streptococcus
6
Streptococcus pneumoniae
20b. OTHER BACTERIAL SPECIES ISOLATED FROM ANY NORMALLY
STERILE SITE: (specify)
22. DATE FIRST POSITIVE
CULTURE OBTAINED:
21. 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
Pleural fluid
1
Joint
1
Internal body site (specify)_____________
1
1
8b. If YES, hospital I.D.:
1
1
Meningitis
Unknown
1
19. TYPES OF INFECTION CAUSED BY ORGANISM: (Check all that apply)
1
1
9
12b. RACE: (Check all that apply)
12a. ETHNIC ORIGIN:
Yrs.
No
8a. Was patient transferred
from another hospital?
17b. If pregnant or postpartum, what was the outcome of fetus:
17a. At time of first positive culture,
patient was:
2
14. TYPE OF INSURANCE: (Check all that apply)
Unknown
______ft ______ in OR ______ cm OR
Yes
7b. If resident of a long term
care facility, what was the
name of the facility?
11. SEX:
Year
4b. HOSPITAL I.D. WHERE
PATIENT TREATED:
6. If patient was hospitalized, was this patient admitted to the
ICU during hospitalization?
Year
No
7a. Where was the patient a resident at time of initial culture?
Mo.
OMB No. 0920-0802
– SHADED AREAS FOR OFFICE USE ONLY –
If YES, date of admission:
2
Hospital:
(Zip Code)
A CORE COMPONENT OF THE EMERGING INFECTIONS PROGRAM NETWORK
5. WAS PATIENT
HOSPITALIZED?
1
(Date Specimen Collected)
Mo.
Day
Year
Other normally sterile site (specify)______________________________________
23. OTHER SITES FROM WHICH ORGANISM
ISOLATED: (Check all that apply)
1
Placenta
1
Middle ear
1
Amniotic fluid
1
Sinus
1
Wound
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 REV. 2-2010
– ACTIVE BACTERIAL CORE SURVEILLANCE CASE REPORT –
– IMPORTANT – PLEASE COMPLETE THE BACK OF THIS FORM –
Page 1 of 2
24. UNDERLYING CAUSES OR PRIOR ILLNESSES: (Check all that apply OR if NONE or CHART UNAVAILABLE, check appropriate box) 1
None
1
Unknown
Current Smoker
1
Asthma
1
Alcohol Abuse
1
Cochlear Implant
1
Multiple Myeloma
1
Emphysema/COPD
1
Atherosclerotic Cardiovascular
1
Deaf/Profound Hearing Loss
1
Sickle Cell Anemia
Disease (ASCVD)/CAD
1
Solid Organ Malignancy
Splenectomy/Asplenia
Systemic Lupus
Erythematosus (SLE)
1
1
1
Solid Organ Transplant
Immunoglobulin Deficiency
Diabetes Mellitus
Heart Failure/CHF
1
1
1
1
Immunosuppressive Therapy
(Steroids, Chemotherapy, Radiation)
Nephrotic Syndrome
Obesity
1
1
1
Renal Failure/Dialysis
CSF Leak
Premature Birth
(specify gestational age at birth)
1
1
HIV Infection
1
IVDU
Chronic Skin Breakdown
Leukemia
1
1
1
1
AIDS or CD4 count <200
Other Prior Illness (specify)
Hodgkin’s Disease/Lymphoma
Cerebral Vascular Accident (CVA)/Stroke
1
1
1
1
Bone Marrow Transplant (BMT)
1
Cirrhosis/Liver Failure
1
Complement Deficiency
1
(wks)
– IMPORTANT – PLEASE COMPLETE FOR THE RELEVANT ORGANISMS:
HAEMOPHILUS
INFLUENZAE
DOSE
25a. If <15 years of age and serotype ‘b’ or ‘unknown’ did
1 Yes 2
No
9
Unknown
patient receive Haemophilus influenzae b vaccine?
If YES, please complete the list below.
DATE GIVEN
LOT NUMBER
VACCINE NAME
MANUFACTURER
Mo.
Day
25b. Were records obtained to verify
vaccination history? (<5 years of age only)
1
Year
1
Yes
2
No
If YES, what was the source of the
information? (Check all that apply)
2
3
4
1
Vaccine Registry
1
Healthcare Provider
1
Other (specify)
25c. What was the serotype?
1
b
2
Not Typeable
NEISSERIA MENINGITIDIS
26. What was the serogroup?
3
a
4
c
5
d
6
e
7
f
8
Other (specify)
A
3
C
5
W135
9
Unknown
2
B
4
Y
6
Not groupable
8
Other (specify)
1
Yes 2
No
9
1
Menactra®, Tetravalent Meningococcal
Conjugate Vaccine (MCV4)
1
1
Other (specify)
Not Known
1
30. Did the patient have surgery?
Yes 2
Mo.
Yes 2
No
9
Unknown
Yes 2
No
9
Unknown
If YES, please note which pneumococcal vaccine was received:
(Check all that apply)
List most recent date for each vaccine
Mo.
Day
Year
1
Prevnar®, 7-valent Pneumococcal Conjugate Vaccine (PCV7)
1
Prevnar-13®, 13-valent Pneumococcal Conjugate Vaccine (PCV13)
1
Pneumovax®, 23-valent Pneumococcal Polysaccharide Vaccine (PPV23)
If between 3 and 59 months of age and an isolate is available for
serotyping, please complete the Invasive Pneumococcal Disease in Children
expanded form.
(#30–32 refer to the 7 days
prior to first positive culture)
GROUP A STREPTOCOCCUS
1
LOT NUMBER
DATE GIVEN
VACCINE NAME
Menomune®, Tetravalent Meningococcal
Polysaccharide Vaccine (MPSV4)
1
STREPTOCOCCUS PNEUMONIAE
29. If <15 years of age, did patient receive pneumococcal vaccine?
Unknown
If YES, please complete the following information:
1
Not Tested or Unknown
27. Is patient currently attending college?
(15 – 24 years only)
1
28. Did patient receive meningococcal vaccine?
9
No
Day
9
31. Did the patient deliver a baby (vaginal or C-section)?
1
Unknown
Year
Yes 2
If YES,
date of delivery:
If YES,date of surgery:
No
9
32. Did patient have:
Unknown
Mo.
Day
Year
INFLUENZA 33. Did this patient have a positive flu test 10 days prior to or following any ABCs positive culture?
1
Yes
1
Varicella
1
Penetrating trauma
1
Blunt trauma
2
No
9
1
Surgical wound
(post operative)
1
Burns
Unknown
34. COMMENTS:
– SURVEILLANCE OFFICE USE ONLY –
35. Was case first
identified through
audit?
1
Yes 2
9
Unknown
No
36. CRF Status:
1
2
3
4
Complete
Incomplete
Edited & Correct
Chart unavailable
after 3 requests
37. Does this case have
recurrent disease with
the same pathogen?
1
Yes 2
9
Unknown
38. 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. 2-2010
– ACTIVE BACTERIAL CORE SURVEILLANCE CASE REPORT –
Day
39. Initials of
S.O.:
Year
Date:
/
/
Page 2 of 2
| File Type | application/pdf |
| File Modified | 2010-02-23 |
| File Created | 2010-02-23 |