*required for saving **conditionally required based upon monitoring selection in Monthly Reporting Plan
Facility ID #: __________ *Month:______ *Year:_____ *Location Code:_______
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**Resident Days:__________ **Resident Admissions:_________________
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LabID Event Reporting
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Specific Organism Type
| MRSA
| VRE
| CephR- Klebsiella
| CRE- Ecoli
| CRE-Klebsiella
| MDR- Acinetobacter
| C. difficile
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Infection Surveillance
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LabID Event (All specimens)
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LabID Event (Blood specimens only)
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Process Measures (Optional)
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Hand Hygiene ** Performed:_____ ** Indicated:_____
| Gown and Gloves ** Used:_____ ** Indicated:_____
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