Facility ID#: ________________
| MedAdmin ID# _________________________
|
*HCW ID#: _____________________
|
HCW Name, Last: ___________________ First: ________________________ Middle: _____________
|
*Gender: F M Other *Date of Birth: ____/_____/________
|
*Infectious Agent: ________________ *Exposure Event #: ____________________
|
Initial Postexposure Prophylaxis
|
Indication: Prophylaxis *Time between exposure and first dose: ________ hours
|
*Drug: _______________ *Drug: _______________ *Drug: _______________ *Drug: _______________
|
*Date Started: ____/____/______ *Date Stopped: ____/____/______
|
*Reason for Stopping (select one):
|
□ Completion of drug therapy □ Source patient was HIV negative □ Adverse reactions
|
□ Lab results □ HCW choice □ Possible anti-retroviral resistance
|
□ Lost to follow up
|
PEP Change 1 Indicate any change from initial PEP.
|
Indication: Prophylaxis
|
**Drug: ______________ **Drug: ______________ **Drug: ______________ **Drug: ______________
|
**Date Started: ____/____/______ **Date Stopped: ____/____/______
|
**Reason for Stopping: (select one):
|
□ Completion of drug therapy □ Source patient was HIV negative □ Adverse reactions
|
□ Lab results □ HCW choice □ Possible anti-retroviral resistance
|
□ Lost to follow up
|
PEP Change 2 Indicate any change from first change in PEP.
|
Indication: Prophylaxis
|
**Drug: ______________ **Drug: ______________ **Drug: ______________ **Drug: ______________
|
**Date Started: ____/____/______ **Date Stopped: ____/____/______
|
**Reason for Stopping: ________________________________________________________________
|
□ Completion of drug therapy □ Source patient was HIV negative □ Adverse reactions
|
□ Lab results □ HCW choice □ Possible anti-retroviral resistance
|
□ Lost to follow up
|
Adverse Reactions
|
(Select all that apply):
|
□ Abdominal pain
| □ Flank pain
| □ Loss of appetite
| □ Numbness in extremities
|
□ Arthralgia
| □ Headache
| □ Lymphadenopathy
| □ Paresthesia
|
□ Dark urine
| □ Insomnia
| □ Malaise/fatigue
| □ Rash
|
□ Diarrhea
| □ Involuntary weight loss
| □ Myalgia
| □ Somnolence
|
□ Dizziness
| □ Jaundice
| □ Nausea
| □ Spleen enlargement
|
□ Emotional distress
| □ Light stools
| □ Nephrolithiasis
| □ Vomiting
|
□ Fever
| □ Liver enlargement
| □ Night sweats
| □ Other (specify): ______________
|
| | | | □ Unknown
|
Assurance of Confidentiality: The voluntarily provided 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 15 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, Reports Clearance Officer, 1600 Clifton Rd., MS D-74, Atlanta, GA 30333, ATTN: PRA (0920-0666).
CDC 57.206 (Front) , v6.4
|
