HAI and Antimicrobial Use Point Prevalence Survey

Prevalence Survey of Healthcare Associated Infections (HAIs) and Antimicrobial Use in U.S. Acute Care Hospitals

AttachmentB_0920-0852_OMBApprovedDataCollectionForm

HAI and Antimicrobial Use Point Prevalence Survey - phase 3

OMB: 0920-0852

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Form Approved

OMB No. 0920-XXXX

Exp. Date xx/xx/20xx

Form Approved

OMB No. 0920-XXXX

Exp. Date xx/xx/20xx

Form Approved

OMB No. 0920-XXXX

Exp. Date xx/xx/20xx

011 HAI & ANTIMICROBIAL USE POINT PREVALENCE SURVEY

P

Form Approved

OMB No. 0920-0852

Exp. Date 05/31/2013


RIMARY TEAM / EIP TEAM DATA COLLECTION FORM


CDC ID: - Survey date: // Data collector initials: _____


I. Identifiers (for Primary Team and EIP Team use only; identifiers are not transmitted to CDC)



Patient name: ___________________________________

(Last, First, MI)


Date of birth: //


Hospital name: __________________________________


Hospital unit name: ______________________________


Room number: __________________________________


Medical record no.: ______________________________



II. Demographics




Age: _______ years months days



Admission date: //


Gender: M F Unknown


CDC location code: __________________________


Race (check all that apply):

American Indian or Alaska Native

Black or African American

Native Hawaiian or other Pacific Islander

Asian


White

Other race

Unknown



Ethnicity:

Hispanic or Latino

Not Hispanic or Latino

Unknown



III. Risk factors (in place on the survey date)

Urinary catheter:

No Yes Unknown


Ventilator:

No Yes Unknown

Central line:

No Yes


Unknown

If “Yes,” check all that apply:

PICC Femoral line Other central line Unknown



IV. Antimicrobials

On antimicrobials on the survey date or the calendar day prior to the survey date:

No Yes Unknown


**Qualification for hemodialysis and peritoneal dialysis patients ONLY**


On any of the following antimicrobials in the 4 calendar days prior to the survey date: vancomycin, amikacin, gentamicin, tobramycin, streptomycin, kanamycin



NA, not a dialysis patient



No Yes Unknown


FORM IS COMPLETE

Public reporting burden of this collection of information is estimated to average 7 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/ATSDR Reports Clearance Officer, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA 0920-0852.
























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AuthorShelley Magill
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