Form 57.75CC List of Blood Isolates

O MB No. 0920-0666 Exp. date: xx-xx-20xx

List of Blood Isolates

Hospital:

Patient name: Patient number:

Date first positive blood culture (for any species) (Day 0):

List all unique organisms (unique species, or genus if not identified to the species level) isolated during Day 0 through Day 6. List each organism once regardless of how many times isolated. Complete one copy of the Manual Categorization of Positive Blood Cultures form (CDC 57.75DD) for each organism listed here.

Organism 1: ________________

Organism 2: ________________

Organism 3: ________________

Organism 4: ________________

Organism 5: ________________

Organism 6: ________________

Assurance of Confidentiality: The information obtained in this surveillance system that would permit identification of any individual or institution is collected with a guarantee that it will be held in strict confidence, will be used only for the purposes stated, and will not otherwise be disclosed or released without the consent of the individual, or the institution in accordance with Sections 304, 306 and 308(d) of the Public Health Service Act (42 USC 242b, 242k, and 242m(d)).

Public reporting burden of this collection of information is estimated to average 1 hour 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, Project Clearance Officer, 1600 Clifton Road, MS D-79, Atlanta, GA 30333, ATTN: PRA (0920-0666). Do not send the completed form to this address.

CDC 57.75CC Rev. 1, Effective date:. xx/xx/20xx