Prescribing Quality Form

CAPEventForm_v8_20140626

ANTIMICROBIAL PRESCRIBING QUALITY EVALUATION:
COMMUNITY ACQUIRED PNEUMONIA EVENT FORM

CDCID:

-

Date:

/

/

Data collector initials: _____

Identifiers (for EIP Team use only; do not transmit to CDC)
Name: __________________________________

Hospital code: _____

Date of birth: ____ / ____ /____

Medical record no.: _______________________

Case identification and eligibility
A. Eligible ICD-9 codes recorded for this patient (check all that apply):
480.0
480.1
480.2
480.3
480.8
480.9
481
482.31
482.32
482.39
482.40
482.41
482.49
482.81
482.9
483.0
483.1
483.2
483.8
485
486
None  If “None,” stop here. This patient is NOT eligible for inclusion.

482.0
482.82
487.0

482.1
482.83
487.1

482.2
482.84
487.8

482.30
482.89

B. Present on Admission? Yes
No
Unknown
If “No” or “Unknown,” stop here. This patient is NOT eligible for inclusion.
C. Is there documentation in the medical record that ≥1 antibiotic was given for an indication of CAP?
Yes
No
Unknown
If “No” or “Unknown,” stop here. This patient is NOT eligible for inclusion.
D. Age >=1 year? Yes
No
Unknown
If “No” or “Unknown,” stop here. This patient is NOT eligible for inclusion.
E. Is there documentation in the medical record of any of the following?
Nursing home or long term care facility residence prior to admission
Hospitalized >=2 days in the 90 days prior to admission
Received IV antibiotic therapy in the 30 days prior to admission
Received cancer chemotherapy in the 30 days prior to admission
Received wound care in the 30 days prior to admission
Chronic hemodialysis
Home mechanical ventilation
AIDS
Solid organ, bone marrow, or stem cell transplant
Long-term (>30 days) high-dose corticosteroid treatment
Other congenital or acquired immunodeficiency
Cystic fibrosis
If any of these is indicated as present, stop here. This patient is NOT eligible for inclusion.
F. Based on A thru E above, confirm patient eligibility:

Not eligible stop.

Eligible  complete rest of form.

Demographic characteristics, hospitalization dates and outcome
1. Admission date: ____ / ____ /____

2. Discharge date: ____ / ____ /____ or

3. Age: _______

4. Sex:

years

or

Unknown

5. Race (check all that apply):
American Indian or Alaska Native
Asian
Black or African American

M

F

Native Hawaiian/other Pacific Islander
White
Unknown

8. Patient outcome at time of hospital discharge:

Survived

9. Where did the patient reside the day prior to this admission?
Homeless
Incarcerated
Other _____________________

Died

Unknown

Unknown
6. Ethnicity:
Hispanic or Latino
Not Hispanic or Latino
Unknown

Unknown

Private residence
Unknown

Another acute care hospital

CDCID:______________________

CAPEventForm_v8_20140626

Antimicrobial allergies
12. Is an antimicrobial drug allergy recorded in the medical record?
Yes
12b. If yes, specify drug class or classes to which patient is allergic, and reaction(s):
Drug class

Nausea,
vomiting
and/or
diarrhea

Hives or
urticaria

Other
skin
rash

Wheezing,
throat
tightness,
trouble
breathing

Angioedema
or face
swelling

Anaphylaxis

No

Unknown

Not
specified

Other (specify)

Penicillins

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes____________

Cephalosporins

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes____________

Sulfa drugs

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes____________

Macrolides

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes____________

Fluoroquinolones

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes____________

Vancomycin

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes____________

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes____________

Other (specify):
________________

13. Underlying conditions: check all that apply.
If none or no chart available, check appropriate box: None or
Unknown
Alcoholism
HIV without AIDS
Asplenia
Leukemia
Asthma
Lymphoma or multiple myeloma
Cerebrovascular disease/stroke (except hemiplegia)
Previous documented MRSA colonization or infection
Chronic cognitive deficit
Myocardial infarction
Chronic kidney disease
Peptic ulcer disease
Chronic liver disease
Peripheral vascular disease
Chronic obstructive pulmonary disease or emphysema
Pregnancy
Chronic lung disease (other than COPD/emphysema)
Sickle cell disease
Congenital heart disease
Smoking
Solid tumor malignancy, metastatic
Congestive heart failure
Connective tissue disease
Dementia
Diabetes mellitus with complications
Diabetes mellitus without complications
Hemiplegia

Solid tumor malignancy, not metastatic
Vaccination, pneumococcal
Vaccination for influenza in past year
Vaccinations “up to date” (pediatric only)

Pneumonia signs and symptoms
14. CAP onset date (mm/dd/yy): ___ / ___ /___ or

Prior to hospitalization but specific date unknown

15. CAP signs and symptoms (check all that apply):
Fever
Increased secretions/sputum production
Chills or rigors
Hemoptysis
Cough
Chest pain
Dyspnea
Mental status changes or functional decline
Increased oxygen requirements
Apnea
Sore throat
Rhinorrhea
16. Did the patient require mechanical ventilation at any time during hospitalization?
16b. If yes, was the patient extubated/removed from mechanical ventilation before discharge?

Grunting
Nasal flaring
Head bobbing
Chest wall retractions
Wheezing
Muscle aches
None documented
Yes
Yes

No
No

Unknown
Unknown

CDCID:______________________

CAPEventForm_v8_20140626

17. Chest imaging: complete table below or check
None or
Unknown
If multiple chest imaging tests on a single date, make one entry for that date that summarizes any findings that are present
among the multiple imaging tests. If
No.
1

Date
___ / ___ / ___

Bronchopneumonia/pneumonia
New or worsening infiltrates

Findings on radiograph or CT scan
Air space density/opacity
Consolidation
No evidence of pneumonia
Cavitation

___ / ___ / ___

Bronchopneumonia/pneumonia
New or worsening infiltrates

Air space density/opacity
No evidence of pneumonia

Consolidation
Cavitation

___ / ___ / ___

Bronchopneumonia/pneumonia
New or worsening infiltrates

Air space density/opacity
No evidence of pneumonia

Consolidation
Cavitation

___ / ___ / ___

Bronchopneumonia/pneumonia
New or worsening infiltrates

Air space density/opacity
No evidence of pneumonia

Consolidation
Cavitation

___ / ___ / ___

Bronchopneumonia/pneumonia
New or worsening infiltrates

Air space density/opacity
No evidence of pneumonia

Consolidation
Cavitation

2

3

4

5

18. Infections present during the hospitalization: complete table, or check
If more than 4, enter the first 4 that were present.
No.

Infection
(code)

Onset date

None or

Pleural effusion
Cannot rule out pneumonia
None of these
Pleural effusion
Cannot rule out pneumonia
None of these
Pleural effusion
Cannot rule out pneumonia
None of these
Pleural effusion
Cannot rule out pneumonia
None of these
Pleural effusion
Cannot rule out pneumonia
None of these

Unknown

Signs and symptoms documented in medical record
(check all that apply)

Was infection
treated with
antimicrobials?

Cough or dyspnea
Nausea or vomiting
Pus, drainage, abscess
Diarrhea
None of these
Redness or swelling
Yes
1
Fever
Other____________
Urinary frequency
No
Hypotension
Pain at infection site
Urinary urgency
Unknown
Mental status change
Positive imaging
Unknown
Cough or dyspnea
Nausea or vomiting
Pus, drainage, abscess
Before hospitalization
Diarrhea
None of these
Redness or swelling
Yes
Hospital days 1-2
2
Fever
Other____________
Urinary frequency
No
On/after hospital day 3
Hypotension
Pain at infection site
Urinary urgency
Unknown
Unknown
Mental status change
Positive imaging
Unknown
Cough or dyspnea
Nausea or vomiting
Pus, drainage, abscess
Before hospitalization
Diarrhea
None of these
Redness or swelling
Yes
Hospital days 1-2
3
Fever
Other____________
Urinary frequency
No
On/after hospital day 3
Hypotension
Pain at infection site
Urinary urgency
Unknown
Unknown
Mental status change
Positive imaging
Unknown
Infection codes: BJI, BSI, CNS, CVI, ENT, GTI, HEB, IAB, LRI, Other (specify), PNEU, REP, SSI (specify site), SST, UND (includes empiric therapy), UTI
Before hospitalization
Hospital days 1-2
On/after hospital day 3
Unknown

CDCID:______________________

CAPEventForm_v8_20140626

Severity of illness
19. Was the patient in an ICU at any time during the hospitalization?

Yes

No

Unknown

If Yes, enter the dates of the first ICU admission during the hospitalization:
ICU admission date: ____ / ____ /____

ICU discharge date: ____ / ____ /____

20. Complete the table below for the specified dates (for all events regardless of response to Q.19)::
SIRS parameter category

Hospital admission:
____ / ____ / ____

Hospital day 3:
____ / ____ / ____

Discharge:
____ / ____ / ____

Temperature:
Highest temperature recorded:

____

°C or

°F or

Unk

____

°C or

°F or

Unk

____

°C or

°F or

Unk

Lowest temperature recorded:

____

°C or

°F or

Unk

____

°C or

°F or

Unk

____

°C or

°F or

Unk

Heart rate:
Highest heart rate recorded:

____ bpm or

Unk

____ bpm or

Unk

____ bpm or

Unk

Lowest heart rate recorded:
Respiratory:

____ bpm or

Unk

____ bpm or

Unk

____ bpm or

Unk

Highest respiratory rate recorded:

____ bpm or

Unk

____ bpm or

Unk

____ bpm or

Unk

Lowest arterial PaCO2 recorded:

____ mmHg or

Mechanically ventilated:
White blood cells:
Highest WBC count recorded:

Yes

Unk

No

____ mmHg or

Unknown

________ cells/mm3 or
3

Lowest WBC count recorded:

________ cells/mm or

Highest %bands recorded:

____ % or

Unk
Unk

Unk

Yes

Unk

No

Unknown

________ cells/mm3 or
3

________ cells/mm or
____ % or

____ mmHg or

Unk
Unk

Unk

Yes

Unk

No

Unknown

________ cells/mm3 or
3

________ cells/mm or
____ % or

Unk
Unk

Unk

Blood pressure:
Lowest systolic blood pressure:

____ mmHg or

Unk

____ mmHg or

Unk

____ mmHg or

Unk

Lowest mean arterial pressure:

____ mmHg or

Unk

____ mmHg or

Unk

____ mmHg or

Unk

On vasopressors
Serum lactate (lactic acid)

Yes
No
________ mg/dL or

Unknown
Unk

Yes
No
________ mg/dL or

Unknown
Unk

Yes
No
Unknown
Intentionally left blank

CDCID:______________________

CAPEventForm_v8_20140626

21. Antimicrobial administration: complete the table for all antimicrobials administered during the hospitalization.
Drug name

Start date (mm/dd/yy)
and route
____ / ____ / ____
IV
IM

Oral/enteral
Inhaled

____ / ____ / ____
IV
IM

Oral/enteral
Inhaled

____ / ____ / ____
IV
IM

Oral/enteral
Inhaled

____ / ____ / ____
IV
IM

Oral/enteral
Inhaled

____ / ____ / ____
IV
IM

Oral/enteral
Inhaled

____ / ____ / ____
IV
IM

Oral/enteral
Inhaled

____ / ____ / ____
IV
IM

Oral/enteral
Inhaled

____ / ____ / ____
IV
IM

Oral/enteral
Inhaled

____ / ____ / ____
IV
IM

Oral/enteral
Inhaled

____ / ____ / ____
IV
IM

Oral/enteral
Inhaled

End date (mm/dd/yy)
and route
____ / ____ / ____
IV
IM

Oral/enteral
Inhaled

____ / ____ / ____
IV
IM

Oral/enteral
Inhaled

____ / ____ / ____
IV
IM

Oral/enteral
Inhaled

____ / ____ / ____
IV
IM

Oral/enteral
Inhaled

____ / ____ / ____
IV
IM

Oral/enteral
Inhaled

____ / ____ / ____
IV
IM

Oral/enteral
Inhaled

____ / ____ / ____
IV
IM

Oral/enteral
Inhaled

____ / ____ / ____
IV
IM

Oral/enteral
Inhaled

____ / ____ / ____
IV
IM

Oral/enteral
Inhaled

____ / ____ / ____
IV
IM

Oral/enteral
Inhaled

Indication
MedProph
SurProph
NonInfect

Treatment 
Unknown

MedProph
SurProph
NonInfect

Treatment 
Unknown

MedProph
SurProph
NonInfect

Treatment 
Unknown

MedProph
SurProph
NonInfect

Treatment 
Unknown

MedProph
SurProph
NonInfect

Treatment 
Unknown

MedProph
SurProph
NonInfect

Treatment 
Unknown

MedProph
SurProph
NonInfect

Treatment 
Unknown

MedProph
SurProph
NonInfect

Treatment 
Unknown

MedProph
SurProph
NonInfect

Treatment 
Unknown

MedProph
SurProph
NonInfect

Treatment 
Unknown

Discharge CAP prescribing
22. Was an antibiotic prescribed at discharge to treat CAP?
Yes
No
Unknown
22b. If yes, enter antibiotic #1 name: _________________ No. days prescribed: ________ or Unknown
enter antibiotic #2 name: _________________ No. days prescribed: ________ or Unknown

If treatment: BJI
BSI
CNS
CVI
ENT
GTI
HEB
IAB
LRI
PNEU
REP
UND
UTI
SSI (site): _____________
Other: ______________________
If treatment: BJI
BSI
CNS
CVI
ENT
GTI
HEB
IAB
LRI
PNEU
REP
UND
UTI
SSI (site): _____________
Other: ______________________
If treatment: BJI
BSI
CNS
CVI
ENT
GTI
HEB
IAB
LRI
PNEU
REP
UND
UTI
SSI (site): _____________
Other: ______________________
If treatment: BJI
BSI
CNS
CVI
ENT
GTI
HEB
IAB
LRI
PNEU
REP
UND
UTI
SSI (site): _____________
Other: ______________________
If treatment: BJI
BSI
CNS
CVI
ENT
GTI
HEB
IAB
LRI
PNEU
REP
UND
UTI
SSI (site): _____________
Other: ______________________
If treatment: BJI
BSI
CNS
CVI
ENT
GTI
HEB
IAB
LRI
PNEU
REP
UND
UTI
SSI (site): _____________
Other: ______________________
If treatment: BJI
BSI
CNS
CVI
ENT
GTI
HEB
IAB
LRI
PNEU
REP
UND
UTI
SSI (site): _____________
Other: ______________________
If treatment: BJI
BSI
CNS
CVI
ENT
GTI
HEB
IAB
LRI
PNEU
REP
UND
UTI
SSI (site): _____________
Other: ______________________
If treatment: BJI
BSI
CNS
CVI
ENT
GTI
HEB
IAB
LRI
PNEU
REP
UND
UTI
SSI (site): _____________
Other: ______________________
If treatment: BJI
BSI
CNS
CVI
ENT
GTI
HEB
IAB
LRI
PNEU
REP
UND
UTI
SSI (site): _____________
Other: ______________________

SST

SST

SST

SST

SST

SST

SST

SST

SST

SST

CDCID: ______________________

CAPEventForm_v7_20140626

23. Microbiology data: record cultures or other microbiology tests collected during the hospitalization.

No.

1

Specimen

Blood
Sputum
ETA
BAL
Urine
Other ______

Collect date
(mm/dd/yy)

___ / ___ / ___

2

Blood
Sputum
ETA
BAL
Urine
Other ______

___ / ___ / ___

3

Blood
Sputum
ETA
BAL
Urine
Other ______

___ / ___ / ___

4

Blood
Sputum
ETA
BAL
Urine
Other ______

___ / ___ / ___

5

Blood
Sputum
ETA
BAL
Urine
Other ______

___ / ___ / ___

6

Blood
Sputum
ETA
BAL
Urine
Other ______

___ / ___ / ___

7

Blood
Sputum
ETA
BAL
Urine
Other ______

___ / ___ / ___

8

Blood
Sputum
ETA
BAL
Urine
Other ______

___ / ___ / ___

9

Blood
Sputum
ETA
BAL
Urine
Other ______

___ / ___ / ___

10

Blood
Sputum
ETA
BAL
Urine
Other ______

___ / ___ / ___

Test result
final date
(mm/dd/yy)

___ / ___ / ___

___ / ___ / ___

___ / ___ / ___

___ / ___ / ___

___ / ___ / ___

___ / ___ / ___

___ / ___ / ___

___ / ___ / ___

___ / ___ / ___

___ / ___ / ___

Positive
or
negative

Neg
Pos
Unk
Neg
Pos
Unk
Neg
Pos
Unk
Neg
Pos
Unk
Neg
Pos
Unk
Neg
Pos
Unk
Neg
Pos
Unk
Neg
Pos
Unk
Neg
Pos
Unk
Neg
Pos
Unk

If SA was
identified, is
SA
susceptible
(S) to
methicillin,
oxacillin, or
cefoxitin?

Pathogens identified (insert code) and culture
colony count (CFU/ml, where applicable)

Path1______

<10K

10-49.9K

50-100K

>100K

U

NA

Path2______

<10K

10-49.9K

50-100K

>100K

U

NA

Path3______

<10K

10-49.9K

50-100K

>100K

U

NA

Path1______

<10K

10-49.9K

50-100K

>100K

U

NA

Path2______

<10K

10-49.9K

50-100K

>100K

U

NA

Path3______

<10K

10-49.9K

50-100K

>100K

U

NA

Path1______

<10K

10-49.9K

50-100K

>100K

U

NA

Path2______

<10K

10-49.9K

50-100K

>100K

U

NA

Path3______

<10K

10-49.9K

50-100K

>100K

U

NA

Path1______

<10K

10-49.9K

50-100K

>100K

U

NA

Path2______

<10K

10-49.9K

50-100K

>100K

U

NA

Path3______

<10K

10-49.9K

50-100K

>100K

U

NA

Path1______

<10K

10-49.9K

50-100K

>100K

U

NA

Path2______

<10K

10-49.9K

50-100K

>100K

U

NA

Path3______

<10K

10-49.9K

50-100K

>100K

U

NA

Path1______

<10K

10-49.9K

50-100K

>100K

U

NA

Path2______

<10K

10-49.9K

50-100K

>100K

U

NA

Path3______

<10K

10-49.9K

50-100K

>100K

U

NA

Path1______

<10K

10-49.9K

50-100K

>100K

U

NA

Path2______

<10K

10-49.9K

50-100K

>100K

U

NA

Path3______

<10K

10-49.9K

50-100K

>100K

U

NA

Path1______

<10K

10-49.9K

50-100K

>100K

U

NA

Path2______

<10K

10-49.9K

50-100K

>100K

U

NA

Path3______

<10K

10-49.9K

50-100K

>100K

U

NA

Path1______

<10K

10-49.9K

50-100K

>100K

U

NA

Path2______

<10K

10-49.9K

50-100K

>100K

U

NA

Path3______

<10K

10-49.9K

50-100K

>100K

U

NA

Path1______

<10K

10-49.9K

50-100K

>100K

U

NA

Path2______

<10K

10-49.9K

50-100K

>100K

U

NA

Path3______

<10K

10-49.9K

50-100K

>100K

U

NA

***FORM IS COMPLETE***

Are all pathogens
susceptible (S) to
≥1 antimicrobial
the patient was
getting THE DAY
AFTER THE TEST
RESULT WAS
FINAL?

Yes
No
Unk

Yes
No
Unk

Yes
No
Unk

Yes
No
Unk

Yes
No
Unk

Yes
No
Unk

Yes
No
Unk

Yes
No
Unk

Yes
No
Unk

Yes
No
Unk

Yes
No
Unk

Yes
No
Unk

Yes
No
Unk

Yes
No
Unk

Yes
No
Unk

Yes
No
Unk

Yes
No
Unk

Yes
No
Unk

Yes
No
Unk

Yes
No
Unk

UTIEventForm_v6_20140626

ANTIMICROBIAL PRESCRIBING QUALITY EVALUATION:
URINARY TRACT INFECTION EVENT FORM

CDCID:

-

Date:

/

/

Data collector initials: _____

Identifiers (for EIP Team use only; do not transmit to CDC)
Name: __________________________________

Hospital code: _____

Date of birth: ____ / ____ /____

Medical record no.: _______________________

Case identification and eligibility
A. Eligible ICD-9 codes recorded for this patient (check all that apply):
590.10
590.11
590.2
590.3
590.80
590.81
590.9
None  If “None,” stop here. This patient is NOT eligible for inclusion.

595.0

597.0

597.80

599.0

B. Present on Admission? Yes
No
Unknown
If “No” or “Unknown,” stop here. This patient is NOT eligible for inclusion.
C. Is there documentation in the medical record that ≥1 antibiotic was given for an indication of UTI?
Yes
No
Unknown
If “No” or “Unknown,” stop here. This patient is NOT eligible for inclusion.
D. Age >=1 year? Yes
No
Unknown
If “No” or “Unknown,” stop here. This patient is NOT eligible for inclusion.
E. Based on A thru D above, confirm patient eligibility:

Eligible  complete rest of form.

Not eligible stop.

Demographic characteristics, hospitalization dates and outcome
1. Admission date: ____ / ____ /____

2. Discharge date: ____ / ____ /____ or

3. Age: _______

4. Sex:

years

or

Unknown

5. Race (check all that apply):
American Indian or Alaska Native
Asian
Black or African American

M

F

Native Hawaiian/other Pacific Islander
White
Unknown

8. Patient outcome at time of hospital discharge:

Survived

Died

Unknown

Unknown
6. Ethnicity:
Hispanic or Latino
Not Hispanic or Latino
Unknown

Unknown

Healthcare exposures
9. Where did the patient reside the day prior to this admission?
Private residence
Long term care/SNF
LTACH
Another acute care hospital
Other _________________________
Unknown
10. In the 30 days prior to admission, did the patient receive:
IV antimicrobials
Cancer chemotherapy
Wound care

Dialysis

Surgery

Homeless

None

Incarcerated

Unknown

11. Was the patient hospitalized in an acute care hospital for >=2 days in the 90 days prior to this admission?
Yes
No
Unknown

CDCID: ___________________

UTIEventForm_v6_20140626

Antimicrobial allergies
12. Is an antimicrobial drug allergy recorded in the medical record?
Yes
12b. If yes, specify drug class or classes to which patient is allergic, and reaction(s):
Drug class

Nausea,
vomiting
and/or
diarrhea

Hives or
urticaria

Other
skin
rash

Wheezing,
throat
tightness,
trouble
breathing

Angioedema
or face
swelling

Anaphylaxis

No

Unknown

Not
specified

Other (specify)

Penicillins

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes____________

Cephalosporins

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes____________

Sulfa drugs

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes____________

Macrolides

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes____________

Fluoroquinolones

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes____________

Vancomycin

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes____________

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes____________

Other (specify):
________________

13. Underlying conditions: check all that apply.
If none or no chart available, check appropriate box: None or
Unknown
AIDS
Kidney stones/nephrolithiasis
Alcoholism
Leukemia
Asplenia
Lymphoma or multiple myeloma
Asthma
Myocardial infarction
Cerebrovascular disease/stroke (except hemiplegia)
Neutropenia (absolute neutrophil count <500 cells / µL)
Chronic cognitive deficit
Peptic ulcer disease
Chronic kidney disease
Peripheral vascular disease
Chronic liver disease
Pregnancy
Chronic obstructive pulmonary disease or emphysema
Recurrent cystitis or urinary tract infection
Chronic lung disease (other than COPD/emphysema)
Renal stents
Chronic steroid or other immunosuppressive therapy
Sickle cell disease
Congenital urinary tract abnormality (not VUR)
Smoking
Congestive heart failure
Solid tumor malignancy, metastatic (not urologic/renal)
Connective tissue disease
Solid tumor malignancy, not metastatic (not urologic/renal)
Congenital heart disease
Spinal cord injury or paraplegia or quadriplegia
Cystic fibrosis
Transplant, hematopoietic stem cell or bone marrow
Dementia
Transplant, solid organ
Diabetes mellitus with complications
Urostomy or nephrostomy
Diabetes mellitus without complications
Urologic or renal malignancy
Hemiplegia
Vesicoureteral reflux (VUR)
HIV without AIDS
Urinary tract infection signs and symptoms
14. Date of UTI onset (mm/dd/yy): ____ / ____ /____ or
15. Signs and symptoms (check all that apply):
Fever
Frequency
Nausea or vomiting
Visible blood in urine
Urgency
Abdominal pain
Rigors
Urinary incontinence

Prior to hospitalization but specific date unknown

Costovertebral angle (CVA) pain or tenderness
Suprapubic pain, swelling or tenderness
Mental status changes or functional decline
Pain or burning with urination
None documented
16. Indwelling urinary catheter in place at the time of or ≤2 calendar days prior to UTI symptom onset:
Yes
No
Unknown

CDCID: ___________________

UTIEventForm_v6_20140626

16b. If yes, was it changed or removed after the diagnosis of UTI?

Yes

17. Urinalysis: complete table below or check

Unknown if urinalysis done

No.

Urinalysis Date (mm/dd/yy)

None done or

Pyuria (>5 WBCs / hpf)

Positive nitrites

No

Unknown

Positive leukocyte
esterase

Positive bacteria

Positive yeast

1

___ / ___ / ___

Yes

Yes

Yes

Yes

Yes

2

___ / ___ / ___

Yes

Yes

Yes

Yes

Yes

3

___ / ___ / ___

Yes

Yes

Yes

Yes

Yes

4

___ / ___ / ___

Yes

Yes

Yes

Yes

Yes

5

___ / ___ / ___

Yes

Yes

Yes

Yes

Yes

18. Infections present during the hospitalization: complete table, or check
If more than 4, enter the first 4 that were present.
No.

Infection
(code)

Onset date

None or

Signs and symptoms documented in medical record
(check all that apply)

Unknown
Was infection
treated with
antimicrobials?

Cough or dyspnea
Nausea or vomiting
Pus, drainage, abscess
Diarrhea
None of these
Redness or swelling
Yes
1
Fever
Other____________
Urinary frequency
No
Hypotension
Pain at infection site
Urinary urgency
Unknown
Mental status change
Positive imaging
Unknown
Cough or dyspnea
Nausea or vomiting
Pus, drainage, abscess
Before hospitalization
Diarrhea
None of these
Redness or swelling
Yes
Hospital days 1-2
2
Fever
Other____________
Urinary frequency
No
On/after hospital day 3
Hypotension
Pain at infection site
Urinary urgency
Unknown
Unknown
Mental status change
Positive imaging
Unknown
Cough or dyspnea
Nausea or vomiting
Pus, drainage, abscess
Before hospitalization
Diarrhea
None of these
Redness or swelling
Yes
Hospital days 1-2
3
Fever
Other____________
Urinary frequency
No
On/after hospital day 3
Hypotension
Pain at infection site
Urinary urgency
Unknown
Unknown
Mental status change
Positive imaging
Unknown
Infection codes: BJI, BSI, CNS, CVI, ENT, GTI, HEB, IAB, LRI, Other (specify), PNEU, REP, SSI (specify site), SST, UND (includes empiric therapy), UTI
Before hospitalization
Hospital days 1-2
On/after hospital day 3
Unknown

CDCID: ___________________

UTIEventForm_v6_20140626

Severity of illness
19. Was the patient in an ICU at any time during the hospitalization? Yes
No
Unknown
If Yes, enter the dates of the first ICU admission during the hospitalization:
ICU admission date: ____ / ____ /____
ICU discharge date: ____ / ____ /____
20. Complete the table below for the specified dates (for all events regardless of response to Q.19)::
SIRS parameter category

Admission:
____ / ____ / ____

Hospital day 3:
____ / ____ / ____

Discharge:
____ / ____ / ____

Temperature:
Highest temperature recorded:

____

°C or

°F or

Unk

____

°C or

°F or

Unk

____

°C or

°F or

Unk

Lowest temperature recorded:

____

°C or

°F or

Unk

____

°C or

°F or

Unk

____

°C or

°F or

Unk

Heart rate:
Highest heart rate recorded:

____ bpm or

Unk

____ bpm or

Unk

____ bpm or

Unk

Lowest heart rate recorded:
Respiratory:

____ bpm or

Unk

____ bpm or

Unk

____ bpm or

Unk

Highest respiratory rate recorded:

____ bpm or

Unk

____ bpm or

Unk

____ bpm or

Unk

Lowest arterial PaCO2 recorded:

____ mmHg or

Mechanically ventilated:
White blood cells:
Highest WBC count recorded:

Yes

Unk

No

____ mmHg or

Unknown

________ cells/mm3 or
3

Lowest WBC count recorded:

________ cells/mm or

Highest %bands recorded:

____ % or

Unk
Unk

Unk

Yes

Unk

No

Unknown

________ cells/mm3 or
3

________ cells/mm or
____ % or

____ mmHg or

Unk
Unk

Unk

Yes

Unk

No

Unknown

________ cells/mm3 or
3

________ cells/mm or
____ % or

Unk
Unk

Unk

Blood pressure:
Lowest systolic blood pressure:

____ mmHg or

Unk

____ mmHg or

Unk

____ mmHg or

Unk

Lowest mean arterial pressure:

____ mmHg or

Unk

____ mmHg or

Unk

____ mmHg or

Unk

On vasopressors
Serum lactate (lactic acid)

Yes
No
________ mg/dL or

Unknown
Unk

Yes
No
________ mg/dL or

Unknown
Unk

Yes
No
Unknown
Intentionally left blank

UTIEventForm_v6_20140626

21. Antimicrobial administration: complete the table for all antimicrobials administered during the hospitalization.
Drug name

Start date (mm/dd/yy)
and route
____ / ____ / ____
IV
IM

Oral/enteral
Inhaled

____ / ____ / ____
IV
IM

Oral/enteral
Inhaled

____ / ____ / ____
IV
IM

Oral/enteral
Inhaled

____ / ____ / ____
IV
IM

Oral/enteral
Inhaled

____ / ____ / ____
IV
IM

Oral/enteral
Inhaled

____ / ____ / ____
IV
IM

Oral/enteral
Inhaled

____ / ____ / ____
IV
IM

Oral/enteral
Inhaled

____ / ____ / ____
IV
IM

Oral/enteral
Inhaled

____ / ____ / ____
IV
IM

Oral/enteral
Inhaled

____ / ____ / ____
IV
IM

Oral/enteral
Inhaled

End date (mm/dd/yy)
and route
____ / ____ / ____
IV
IM

Oral/enteral
Inhaled

____ / ____ / ____
IV
IM

Oral/enteral
Inhaled

____ / ____ / ____
IV
IM

Oral/enteral
Inhaled

____ / ____ / ____
IV
IM

Oral/enteral
Inhaled

____ / ____ / ____
IV
IM

Oral/enteral
Inhaled

____ / ____ / ____
IV
IM

Oral/enteral
Inhaled

____ / ____ / ____
IV
IM

Oral/enteral
Inhaled

____ / ____ / ____
IV
IM

Oral/enteral
Inhaled

____ / ____ / ____
IV
IM

Oral/enteral
Inhaled

____ / ____ / ____
IV
IM

Oral/enteral
Inhaled

Indication
MedProph
SurProph
NonInfect

Treatment 
Unknown

MedProph
SurProph
NonInfect

Treatment 
Unknown

MedProph
SurProph
NonInfect

Treatment 
Unknown

MedProph
SurProph
NonInfect

Treatment 
Unknown

MedProph
SurProph
NonInfect

Treatment 
Unknown

MedProph
SurProph
NonInfect

Treatment 
Unknown

MedProph
SurProph
NonInfect

Treatment 
Unknown

MedProph
SurProph
NonInfect

Treatment 
Unknown

MedProph
SurProph
NonInfect

Treatment 
Unknown

MedProph
SurProph
NonInfect

Treatment 
Unknown

Discharge UTI prescribing
22. Was an antibiotic prescribed at discharge to treat UTI?
Yes
No
Unknown
22b. If yes, enter antibiotic #1 name: _________________ No. days prescribed: ________ or
enter antibiotic #2 name: _________________ No. days prescribed: ________ or

Unknown
Unknown

If treatment: BJI
BSI
CNS
CVI
ENT
GTI
HEB
IAB
LRI
PNEU
REP
UND
UTI
SSI (site): _____________
Other: ______________________
If treatment: BJI
BSI
CNS
CVI
ENT
GTI
HEB
IAB
LRI
PNEU
REP
UND
UTI
SSI (site): _____________
Other: ______________________
If treatment: BJI
BSI
CNS
CVI
ENT
GTI
HEB
IAB
LRI
PNEU
REP
UND
UTI
SSI (site): _____________
Other: ______________________
If treatment: BJI
BSI
CNS
CVI
ENT
GTI
HEB
IAB
LRI
PNEU
REP
UND
UTI
SSI (site): _____________
Other: ______________________
If treatment: BJI
BSI
CNS
CVI
ENT
GTI
HEB
IAB
LRI
PNEU
REP
UND
UTI
SSI (site): _____________
Other: ______________________
If treatment: BJI
BSI
CNS
CVI
ENT
GTI
HEB
IAB
LRI
PNEU
REP
UND
UTI
SSI (site): _____________
Other: ______________________
If treatment: BJI
BSI
CNS
CVI
ENT
GTI
HEB
IAB
LRI
PNEU
REP
UND
UTI
SSI (site): _____________
Other: ______________________
If treatment: BJI
BSI
CNS
CVI
ENT
GTI
HEB
IAB
LRI
PNEU
REP
UND
UTI
SSI (site): _____________
Other: ______________________
If treatment: BJI
BSI
CNS
CVI
ENT
GTI
HEB
IAB
LRI
PNEU
REP
UND
UTI
SSI (site): _____________
Other: ______________________
If treatment: BJI
BSI
CNS
CVI
ENT
GTI
HEB
IAB
LRI
PNEU
REP
UND
UTI
SSI (site): _____________
Other: ______________________

SST

SST

SST

SST

SST

SST

SST

SST

SST

SST

CDCID: ___________________

UTIEventForm_v6_20140626

23. Microbiology data: record cultures or other microbiology tests collected during the hospitalization.

No.

1

Specimen

Blood
Resp
Urine,cc
Urine,cath
Urine,other
Other ______

Collect date
(mm/dd/yy)

___ / ___ / ___

2

Blood
Resp
Urine,cc
Urine,cath
Urine,other
Other ______

___ / ___ / ___

3

Blood
Resp
Urine,cc
Urine,cath
Urine,other
Other ______

___ / ___ / ___

4

Blood
Resp
Urine,cc
Urine,cath
Urine,other
Other ______

___ / ___ / ___

5

Blood
Resp
Urine,cc
Urine,cath
Urine,other
Other ______

___ / ___ / ___

6

Blood
Resp
Urine,cc
Urine,cath
Urine,other
Other ______

___ / ___ / ___

7

Blood
Resp
Urine,cc
Urine,cath
Urine,other
Other ______

___ / ___ / ___

8

Blood
Resp
Urine,cc
Urine,cath
Urine,other
Other ______

___ / ___ / ___

9

Blood
Resp
Urine,cc
Urine,cath
Urine,other
Other ______

___ / ___ / ___

10

Blood
Resp
Urine,cc
Urine,cath
Urine,other
Other ______

___ / ___ / ___

Test result final
date (mm/dd/yy)

___ / ___ / ___

___ / ___ / ___

___ / ___ / ___

___ / ___ / ___

___ / ___ / ___

___ / ___ / ___

___ / ___ / ___

___ / ___ / ___

___ / ___ / ___

___ / ___ / ___

Positive or
negative

Neg
Pos
Unk
Neg
Pos
Unk
Neg
Pos
Unk
Neg
Pos
Unk
Neg
Pos
Unk
Neg
Pos
Unk
Neg
Pos
Unk
Neg
Pos
Unk
Neg
Pos
Unk
Neg
Pos
Unk

Are all pathogens
susceptible (S) to ≥1
antimicrobial the
patient was getting
THE DAY AFTER
THE TEST RESULT
WAS FINAL?

Pathogens identified (insert code) and culture
colony count (CFU/ml, where applicable)

Path1______

<10K

10-49.9K

50-100K

>100K

U

NA

Path2______

<10K

10-49.9K

50-100K

>100K

U

NA

Path3______

<10K

10-49.9K

50-100K

>100K

U

NA

Path1______

<10K

10-49.9K

50-100K

>100K

U

NA

Path2______

<10K

10-49.9K

50-100K

>100K

U

NA

Path3______

<10K

10-49.9K

50-100K

>100K

U

NA

Path1______

<10K

10-49.9K

50-100K

>100K

U

NA

Path2______

<10K

10-49.9K

50-100K

>100K

U

NA

Path3______

<10K

10-49.9K

50-100K

>100K

U

NA

Path1______

<10K

10-49.9K

50-100K

>100K

U

NA

Path2______

<10K

10-49.9K

50-100K

>100K

U

NA

Path3______

<10K

10-49.9K

50-100K

>100K

U

NA

Path1______

<10K

10-49.9K

50-100K

>100K

U

NA

Path2______

<10K

10-49.9K

50-100K

>100K

U

NA

Path3______

<10K

10-49.9K

50-100K

>100K

U

NA

Path1______

<10K

10-49.9K

50-100K

>100K

U

NA

Path2______

<10K

10-49.9K

50-100K

>100K

U

NA

Path3______

<10K

10-49.9K

50-100K

>100K

U

NA

Path1______

<10K

10-49.9K

50-100K

>100K

U

NA

Path2______

<10K

10-49.9K

50-100K

>100K

U

NA

Path3______

<10K

10-49.9K

50-100K

>100K

U

NA

Path1______

<10K

10-49.9K

50-100K

>100K

U

NA

Path2______

<10K

10-49.9K

50-100K

>100K

U

NA

Path3______

<10K

10-49.9K

50-100K

>100K

U

NA

Path1______

<10K

10-49.9K

50-100K

>100K

U

NA

Path2______

<10K

10-49.9K

50-100K

>100K

U

NA

Path3______

<10K

10-49.9K

50-100K

>100K

U

NA

Path1______

<10K

10-49.9K

50-100K

>100K

U

NA

Path2______

<10K

10-49.9K

50-100K

>100K

U

NA

Path3______

<10K

10-49.9K

50-100K

>100K

U

NA

Yes
No
Unk
Yes
No
Unk
Yes
No
Unk
Yes
No
Unk
Yes
No
Unk
Yes
No
Unk
Yes
No
Unk
Yes
No
Unk
Yes
No
Unk
Yes
No
Unk

VancoEventForm_v6_20140626

ANTIMICROBIAL PRESCRIBING QUALITY EVALUATION:
INTRAVENOUS VANCOMYCIN EVENT FORM

-

CDCID:

/

Date:

/

Data collector initials: _____

Identifiers (for EIP Team use only; do not transmit to CDC)
Name: __________________________________

Hospital code: _____

Date of birth: ____ / ____ /____

Medical record no.: _______________________

Case identification and eligibility
A. Did the patient receive at least 1 dose of intravenous vancomycin during the hospitalization, per the Medication
Administration Record?
Yes
No
Unknown  If “No” or “Unknown,” stop here. This patient is NOT eligible for inclusion.
B. Was vancomycin administered solely for surgical prophylaxis?
Yes
No
Unknown  If “Yes” or “Unknown,” stop here. This patient is NOT eligible for inclusion.
C. Age >=1 year? Yes
No
Unknown
If “No” or “Unknown,” stop here. This patient is NOT eligible for inclusion.
D. Based on A thru C above, confirm patient eligibility:

Not eligible stop.

Eligible  complete rest of form.

Demographic characteristics, hospitalization dates and outcome
1. Admission date: ____ / ____ /____

2. Discharge date: ____ / ____ /____ or

3. Age: _______

4. Sex:

or

Unknown

5. Race (check all that apply):
American Indian or Alaska Native
Asian
Black or African American

M

F

Native Hawaiian/other Pacific Islander
White
Unknown

8. Patient outcome at time of hospital discharge:

Survived

Died

Unknown

Unknown
6. Ethnicity:
Hispanic or Latino
Not Hispanic or Latino
Unknown

Unknown

Healthcare exposures
9. Where did the patient reside the day prior to this admission?
Private residence
Long term care/SNF
LTACH
Another acute care hospital
Other _________________________
Unknown
10. In the 30 days prior to admission, did the patient receive:
IV antimicrobials
Cancer chemotherapy
Wound care

Dialysis

Surgery

Homeless

None

Incarcerated

Unknown

11. Was the patient hospitalized in an acute care hospital for >=2 days in the 90 days prior to this admission?
Yes
No
Unknown

CDCID:________________________

VancoEventForm_v6_20140626

Antimicrobial allergies
12. Is an antimicrobial drug allergy recorded in the medical record?
Yes
12b. If yes, specify drug class or classes to which patient is allergic, and reaction(s):
Drug class

Nausea,
vomiting
and/or
diarrhea

Hives or
urticaria

Other
skin
rash

Wheezing,
throat
tightness,
trouble
breathing

Angioedema
or face
swelling

Anaphylaxis

No

Unknown

Not
specified

Other (specify)

Penicillins

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes____________

Cephalosporins

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes____________

Sulfa drugs

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes____________

Macrolides

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes____________

Fluoroquinolones

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes____________

Vancomycin

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes____________

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes____________

Other (specify):
________________

13. Underlying conditions: check all that apply.
If none or no chart available, check appropriate box: None or
Unknown
AIDS
HIV without AIDS
Alcoholism
IVDU
Asplenia
Leukemia
Asthma
Lymphoma or multiple myeloma
Cerebrovascular disease/stroke (except hemiplegia)
Previous documented MRSA colonization or infection
Chronic cognitive deficit
Myocardial infarction
Chronic kidney disease
Neutropenia (absolute neutrophil count <500 cells / µL)
Chronic liver disease
Peptic ulcer disease
Chronic obstructive pulmonary disease or emphysema
Peripheral vascular disease
Chronic lung disease (other than COPD/emphysema)
Pregnancy
Chronic steroid or other immunosuppressive therapy
Sickle cell disease
Congenital heart disease
Smoking
Congestive heart failure
Solid tumor malignancy, metastatic
Connective tissue disease
Solid tumor malignancy, not metastatic
Cystic fibrosis
Transplant, hematopoietic stem cell or bone marrow
Dementia
Transplant, solid organ
Diabetes mellitus with complications
Vaccination, pneumococcal
Diabetes mellitus without complications
Vaccination for influenza in past year
Hemiplegia
Vaccinations “up to date” (pediatric only)

CDCID:________________________

VancoEventForm_v6_20140626

15. Infections present during the hospitalization: complete table, or check
If more than 4, enter the first 4 that were present.

No.

Infection
(code)

None or

Unknown

Was infection
treated with IV
vancomycin?

Signs and symptoms documented in medical record
(check all that apply)

Onset date

Cough or dyspnea
Nausea or vomiting
Pus, drainage, abscess
Diarrhea
None of these
Redness or swelling
Yes
1
Fever
Other____________
Urinary frequency
No
Hypotension
Pain at infection site
Urinary urgency
Unknown
Mental status change
Positive imaging
Unknown
Cough or dyspnea
Nausea or vomiting
Pus, drainage, abscess
Before hospitalization
Diarrhea
None of these
Redness or swelling
Yes
Hospital days 1-2
2
Fever
Other____________
Urinary frequency
No
On/after hospital day 3
Hypotension
Pain at infection site
Urinary urgency
Unknown
Unknown
Mental status change
Positive imaging
Unknown
Cough or dyspnea
Nausea or vomiting
Pus, drainage, abscess
Before hospitalization
Diarrhea
None of these
Redness or swelling
Yes
Hospital days 1-2
3
Fever
Other____________
Urinary frequency
No
On/after hospital day 3
Hypotension
Pain at infection site
Urinary urgency
Unknown
Unknown
Mental status change
Positive imaging
Unknown
Cough or dyspnea
Nausea or vomiting
Pus, drainage, abscess
Before hospitalization
Diarrhea
None of these
Redness or swelling
Yes
Hospital days 1-2
4
Fever
Other____________
Urinary frequency
No
On/after hospital day 3
Hypotension
Pain at infection site
Urinary urgency
Unknown
Unknown
Mental status change
Positive imaging
Unknown
Infection codes: BJI, BSI, CNS, CVI, ENT, GTI, HEB, IAB, LRI, Other (specify), PNEU, REP, SSI (specify site), SST, UND (includes empiric therapy), UTI
Before hospitalization
Hospital days 1-2
On/after hospital day 3
Unknown

Severity of illness
16. Was the patient in an ICU at any time during the hospitalization? Yes
No
Unknown
If Yes, enter the dates of the first ICU admission during the hospitalization:
ICU admission date: ____ / ____ /____
ICU discharge date: ____ / ____ /____
17. Complete the table below for the specified dates (for all events regardless of response to Q.16):
SIRS parameter category

Hospital admission:

First day of vancomycin:

Discharge:

____ / ____ / ____

____ / ____ / ____

____ / ____ / ____

Temperature:
Highest temperature recorded:

____

°C or

°F or

Unk

____

°C or

°F or

Unk

____

°C or

°F or

Unk

Lowest temperature recorded:

____

°C or

°F or

Unk

____

°C or

°F or

Unk

____

°C or

°F or

Unk

Heart rate:
Highest heart rate recorded:

____ bpm or

Unk

____ bpm or

Unk

____ bpm or

Unk

Lowest heart rate recorded:

____ bpm or

Unk

____ bpm or

Unk

____ bpm or

Unk

Highest respiratory rate recorded:

____ bpm or

Unk

____ bpm or

Unk

____ bpm or

Unk

Lowest arterial PaCO2 recorded:

____ mmHg or

Respiratory:

Mechanically ventilated:

Yes

Unk

No

____ mmHg or

Unknown

Yes

Unk

No

____ mmHg or

Unknown

Yes

Unk

No

Unknown

White blood cells:
Highest WBC count recorded:

________ cells/mm3 or
3

Lowest WBC count recorded:

________ cells/mm or

Highest %bands recorded:

____ % or

Unk
Unk

Unk

________ cells/mm3 or
3

________ cells/mm or
____ % or

Unk

________ cells/mm3 or

Unk

Unk

________ cells/mm3 or

Unk

Unk

____ % or

Unk

Blood pressure:
Lowest systolic blood pressure:

____ mmHg or

Unk

____ mmHg or

Unk

____ mmHg or

Unk

Lowest mean arterial pressure:

____ mmHg or

Unk

____ mmHg or

Unk

____ mmHg or

Unk

On vasopressors
Serum lactate (lactic acid)

Yes

No

________ mg/dL or

Unknown
Unk

Yes

No

________ mg/dL or

Unknown
Unk

Yes

No

Intentionally left blank

Unknown

CDCID:________________________

VancoEventForm_v6_20140626

18. Antimicrobial administration: complete the table for all antimicrobials administered during the hospitalization.
Drug name

Start date (mm/dd/yy)
and route
____ / ____ / ____
IV
IM

Oral/enteral
Inhaled

____ / ____ / ____
IV
IM

Oral/enteral
Inhaled

____ / ____ / ____
IV
IM

Oral/enteral
Inhaled

____ / ____ / ____
IV
IM

Oral/enteral
Inhaled

____ / ____ / ____
IV
IM

Oral/enteral
Inhaled

____ / ____ / ____
IV
IM

Oral/enteral
Inhaled

____ / ____ / ____
IV
IM

Oral/enteral
Inhaled

____ / ____ / ____
IV
IM

Oral/enteral
Inhaled

____ / ____ / ____
IV
IM

Oral/enteral
Inhaled

____ / ____ / ____
IV
IM

Oral/enteral
Inhaled

End date (mm/dd/yy)
and route
____ / ____ / ____
IV
IM

Oral/enteral
Inhaled

____ / ____ / ____
IV
IM

Oral/enteral
Inhaled

____ / ____ / ____
IV
IM

Oral/enteral
Inhaled

____ / ____ / ____
IV
IM

Oral/enteral
Inhaled

____ / ____ / ____
IV
IM

Oral/enteral
Inhaled

____ / ____ / ____
IV
IM

Oral/enteral
Inhaled

____ / ____ / ____
IV
IM

Oral/enteral
Inhaled

____ / ____ / ____
IV
IM

Oral/enteral
Inhaled

____ / ____ / ____
IV
IM

Oral/enteral
Inhaled

____ / ____ / ____
IV
IM

Oral/enteral
Inhaled

Indication
MedProph
SurProph
NonInfect

Treatment 
Unknown

MedProph
SurProph
NonInfect

Treatment 
Unknown

MedProph
SurProph
NonInfect

Treatment 
Unknown

MedProph
SurProph
NonInfect

Treatment 
Unknown

MedProph
SurProph
NonInfect

Treatment 
Unknown

MedProph
SurProph
NonInfect

Treatment 
Unknown

MedProph
SurProph
NonInfect

Treatment 
Unknown

MedProph
SurProph
NonInfect

Treatment 
Unknown

MedProph
SurProph
NonInfect

Treatment 
Unknown

MedProph
SurProph
NonInfect

Treatment 
Unknown

If treatment: BJI
BSI
CNS
CVI
ENT
GTI
HEB
IAB
LRI
PNEU
REP
UND
UTI
SSI (site): _____________
Other: ______________________
If treatment: BJI
BSI
CNS
CVI
ENT
GTI
HEB
IAB
LRI
PNEU
REP
UND
UTI
SSI (site): _____________
Other: ______________________
If treatment: BJI
BSI
CNS
CVI
ENT
GTI
HEB
IAB
LRI
PNEU
REP
UND
UTI
SSI (site): _____________
Other: ______________________
If treatment: BJI
BSI
CNS
CVI
ENT
GTI
HEB
IAB
LRI
PNEU
REP
UND
UTI
SSI (site): _____________
Other: ______________________
If treatment: BJI
BSI
CNS
CVI
ENT
GTI
HEB
IAB
LRI
PNEU
REP
UND
UTI
SSI (site): _____________
Other: ______________________
If treatment: BJI
BSI
CNS
CVI
ENT
GTI
HEB
IAB
LRI
PNEU
REP
UND
UTI
SSI (site): _____________
Other: ______________________
If treatment: BJI
BSI
CNS
CVI
ENT
GTI
HEB
IAB
LRI
PNEU
REP
UND
UTI
SSI (site): _____________
Other: ______________________
If treatment: BJI
BSI
CNS
CVI
ENT
GTI
HEB
IAB
LRI
PNEU
REP
UND
UTI
SSI (site): _____________
Other: ______________________
If treatment: BJI
BSI
CNS
CVI
ENT
GTI
HEB
IAB
LRI
PNEU
REP
UND
UTI
SSI (site): _____________
Other: ______________________
If treatment: BJI
BSI
CNS
CVI
ENT
GTI
HEB
IAB
LRI
PNEU
REP
UND
UTI
SSI (site): _____________
Other: ______________________

SST

SST

SST

SST

SST

SST

SST

SST

SST

SST

Discharge IV vancomycin prescribing
19. Was IV vancomycin prescribed at discharge (i.e., prescribed to be administered to the patient for additional days after hospital discharge)?
Yes

No

Unknown

19b. If yes, enter the duration of the prescription in no. of days:______

Unknown

CDCID:________________________

VancoEventForm_v6_20140626

20. Microbiology data during hospitalization: Record tests/cultures collected within 4 days before vancomycin start date through the vancomycin end date. Do
NOT record screening nares cultures for MRSA in the table. 4 days before vancomycin start date: ____ / ____ / ____ Vancomycin end date: ____ / ____ / ____
20b. MRSA nares surveillance culture done during this admission? Yes
No
Unknown If yes, indicate result:
Negative
Positive
Unknown

No.

1

2

3

4

5

6

7

8

9

10

Specimen

Blood
Urine
Resp
Other _____
Blood
Urine
Resp
Other _____
Blood
Urine
Resp
Other _____
Blood
Urine
Resp
Other _____
Blood
Urine
Resp
Other _____
Blood
Urine
Resp
Other _____
Blood
Urine
Resp
Other _____
Blood
Urine
Resp
Other _____
Blood
Urine
Resp
Other
______
Blood
Urine
Resp
Other______

Pathogens
identified
(insert code)

Pathogen susceptible
to oxacillin,
methicillin or
cefoxitin?

Pathogen susceptible
to penicillin or
ampicillin?

Pathogen susceptible
to vancomycin?

Are all pathogens
susceptible (S) to ≥1
antimicrobial the
patient was getting
THE DAY AFTER THE
DATE THE TEST
RESULT WAS FINAL?

Collect date
(mm/dd/yy)

Test result
final date
(mm/dd/yy)

Positive
or
negative

___ / ___ / ___

___ / ___ / ___

Neg
Pos
Unk

Path1______
Path2______
Path3______

Path1:
Path2:
Path3:

Y
Y
Y

N
N
N

U
U
U

Path1:
Path2:
Path3:

Y
Y
Y

N
N
N

U
U
U

Path1:
Path2:
Path3:

Y
Y
Y

N
N
N

U
U
U

Yes
No
Unk

___ / ___ / ___

___ / ___ / ___

Neg
Pos
Unk

Path1______
Path2______
Path3______

Path1:
Path2:
Path3:

Y
Y
Y

N
N
N

U
U
U

Path1:
Path2:
Path3:

Y
Y
Y

N
N
N

U
U
U

Path1:
Path2:
Path3:

Y
Y
Y

N
N
N

U
U
U

Yes
No
Unk

___ / ___ / ___

___ / ___ / ___

Neg
Pos
Unk

Path1______
Path2______
Path3______

Path1:
Path2:
Path3:

Y
Y
Y

N
N
N

U
U
U

Path1:
Path2:
Path3:

Y
Y
Y

N
N
N

U
U
U

Path1:
Path2:
Path3:

Y
Y
Y

N
N
N

U
U
U

Yes
No
Unk

___ / ___ / ___

___ / ___ / ___

Neg
Pos
Unk

Path1______
Path2______
Path3______

Path1:
Path2:
Path3:

Y
Y
Y

N
N
N

U
U
U

Path1:
Path2:
Path3:

Y
Y
Y

N
N
N

U
U
U

Path1:
Path2:
Path3:

Y
Y
Y

N
N
N

U
U
U

Yes
No
Unk

___ / ___ / ___

___ / ___ / ___

Neg
Pos
Unk

Path1______
Path2______
Path3______

Path1:
Path2:
Path3:

Y
Y
Y

N
N
N

U
U
U

Path1:
Path2:
Path3:

Y
Y
Y

N
N
N

U
U
U

Path1:
Path2:
Path3:

Y
Y
Y

N
N
N

U
U
U

Yes
No
Unk

___ / ___ / ___

___ / ___ / ___

Neg
Pos
Unk

Path1______
Path2______
Path3______

Path1:
Path2:
Path3:

Y
Y
Y

N
N
N

U
U
U

Path1:
Path2:
Path3:

Y
Y
Y

N
N
N

U
U
U

Path1:
Path2:
Path3:

Y
Y
Y

N
N
N

U
U
U

Yes
No
Unk

___ / ___ / ___

___ / ___ / ___

Neg
Pos
Unk

Path1______
Path2______
Path3______

Path1:
Path2:
Path3:

Y
Y
Y

N
N
N

U
U
U

Path1:
Path2:
Path3:

Y
Y
Y

N
N
N

U
U
U

Path1:
Path2:
Path3:

Y
Y
Y

N
N
N

U
U
U

Yes
No
Unk

___ / ___ / ___

___ / ___ / ___

Neg
Pos
Unk

Path1______
Path2______
Path3______

Path1:
Path2:
Path3:

Y
Y
Y

N
N
N

U
U
U

Path1:
Path2:
Path3:

Y
Y
Y

N
N
N

U
U
U

Path1:
Path2:
Path3:

Y
Y
Y

N
N
N

U
U
U

Yes
No
Unk

___ / ___ / ___

___ / ___ / ___

Neg
Pos
Unk

Path1______
Path2______
Path3______

Path1:
Path2:
Path3:

Y
Y
Y

N
N
N

U
U
U

Path1:
Path2:
Path3:

Y
Y
Y

N
N
N

U
U
U

Path1:
Path2:
Path3:

Y
Y
Y

N
N
N

U
U
U

Yes
No
Unk

____ / ____ /
____

____ / ____ /
____

Neg
Pos
Unk

Path1______
Path2______
Path3______

Path1:
Path2:
Path3:

Y
Y
Y

N
N
N

U
U
U

Path1:
Path2:
Path3:

Y
Y
Y

N
N
N

U
U
U

Path1:
Path2:
Path3:

Y
Y
Y

N
N
N

U
U
U

Yes
No
Unk

***FORM IS COMPLETE***

FQEventForm_v6_20140626

ANTIMICROBIAL PRESCRIBING QUALITY EVALUATION:
FLUOROQUINOLONE EVENT FORM

CDCID:

-

Date:

/

/

Data collector initials: _____

Identifiers (for EIP Team use only; do not transmit to CDC)
Name: __________________________________

Hospital code: _____

Date of birth: ____ / ____ /____

Medical record no.: _______________________

Case identification and eligibility
A. Did the patient receive at least 1 dose of a fluoroquinolone (IV or oral/enteral) during the hospitalization, per the
Medication Administration Record?
Yes
No
Unknown  If “No” or “Unknown,” stop here. This patient is NOT eligible for inclusion.
B. Which fluoroquinolones were administered?
Ciprofloxacin
Levofloxacin
Moxifloxacin
None of these  If “None of these” is checked, stop here. This
patient is NOT eligible for inclusion.
C. Age >=18 years? Yes
No
Unknown
If “No” or “Unknown,” stop here. This patient is NOT eligible for inclusion Note that the age cutoff is different than the other
events because children are not included in the fluoroquinolone event.
D. Based on A and C above, confirm patient eligibility:

Eligible  complete rest of form.

Not eligible stop.

Demographic characteristics, hospitalization dates and outcome
1. Admission date: ____ / ____ /____

2. Discharge date: ____ / ____ /____ or

3. Age: _______

4. Sex:

years

or

Unknown

5. Race (check all that apply):
American Indian or Alaska Native
Asian
Black or African American

M

F

Native Hawaiian/other Pacific Islander
White
Unknown

8. Patient outcome at time of hospital discharge:

Survived

Died

Unknown

Unknown
6. Ethnicity:
Hispanic or Latino
Not Hispanic or Latino
Unknown

Unknown

Healthcare exposures
9. Where did the patient reside the day prior to this admission?
Private residence
Long term care/SNF
LTACH
Another acute care hospital
Other _________________________
Unknown
10. In the 30 days prior to admission, did the patient receive:
IV antimicrobials
Cancer chemotherapy
Wound care

Dialysis

Surgery

Homeless

None

Incarcerated

Unknown

11. Was the patient hospitalized in an acute care hospital for >=2 days in the 90 days prior to this admission?
Yes
No
Unknown

CDCID: ________________

FQEventForm_v6_20140626

Antimicrobial allergies
12. Is an antimicrobial drug allergy recorded in the medical record?
Yes
12b. If yes, specify drug class or classes to which patient is allergic, and reaction(s):
Drug class

Nausea,
vomiting
and/or
diarrhea

Hives or
urticaria

Other
skin
rash

Wheezing,
throat
tightness,
trouble
breathing

Angioedema
or face
swelling

Anaphylaxis

No

Unknown

Not
specified

Other (specify)

Penicillins

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes____________

Cephalosporins

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes____________

Sulfa drugs

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes____________

Macrolides

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes____________

Fluoroquinolones

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes____________

Vancomycin

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes____________

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes____________

Other (specify):
________________

13. Underlying conditions: check all that apply.
If none or no chart available, check appropriate box: None or
Unknown
AIDS
HIV without AIDS
Alcoholism
IVDU
Asplenia
Leukemia
Lymphoma or multiple myeloma
Asthma
Cerebrovascular disease/stroke (except hemiplegia)
Previous documented MRSA colonization or infection
Myocardial infarction
Chronic cognitive deficit
Chronic kidney disease
Neutropenia (absolute neutrophil count <500 cells / µL)
Chronic liver disease
Peptic ulcer disease
Chronic obstructive pulmonary disease or emphysema
Peripheral vascular disease
Chronic lung disease (other than COPD/emphysema)
Pregnancy
Chronic steroid or other immunosuppressive therapy
Sickle cell disease
Congenital heart disease
Smoking
Congestive heart failure
Solid tumor malignancy, metastatic
Connective tissue disease
Solid tumor malignancy, not metastatic
Cystic fibrosis
Transplant, hematopoietic stem cell or bone marrow
Dementia
Transplant, solid organ
Diabetes mellitus with complications
Vaccination, pneumococcal
Diabetes mellitus without complications
Vaccination for influenza in past year
Hemiplegia

Vaccinations “up to date” (pediatric only)

CDCID: ________________

FQEventForm_v6_20140626

15. Infections present during the hospitalization: complete table, or check
If more than 4, enter the first 4 that were present.

No.

Infection
(code)

None or

Unknown

Was infection
treated with
fluoroquinolones?

Signs and symptoms documented in medical record
(check all that apply)

Onset date

Cough or dyspnea
Nausea or vomiting
Pus, drainage, abscess
Diarrhea
None of these
Redness or swelling
Yes
1
Fever
Other____________
Urinary frequency
No
Hypotension
Pain at infection site
Urinary urgency
Unknown
Mental status change
Positive imaging
Unknown
Cough or dyspnea
Nausea or vomiting
Pus, drainage, abscess
Before hospitalization
Diarrhea
None of these
Redness or swelling
Yes
Hospital days 1-2
2
Fever
Other____________
Urinary frequency
No
On/after hospital day 3
Hypotension
Pain at infection site
Urinary urgency
Unknown
Unknown
Mental status change
Positive imaging
Unknown
Cough or dyspnea
Nausea or vomiting
Pus, drainage, abscess
Before hospitalization
Diarrhea
None of these
Redness or swelling
Yes
Hospital days 1-2
3
Fever
Other____________
Urinary frequency
No
On/after hospital day 3
Hypotension
Pain at infection site
Urinary urgency
Unknown
Unknown
Mental status change
Positive imaging
Unknown
Cough or dyspnea
Nausea or vomiting
Pus, drainage, abscess
Before hospitalization
Diarrhea
None of these
Redness or swelling
Yes
Hospital days 1-2
4
Fever
Other____________
Urinary frequency
No
On/after hospital day 3
Hypotension
Pain at infection site
Urinary urgency
Unknown
Unknown
Mental status change
Positive imaging
Unknown
Infection codes: BJI, BSI, CNS, CVI, ENT, GTI, HEB, IAB, LRI, Other (specify), PNEU, REP, SSI (specify site), SST, UND (includes empiric therapy), UTI
Before hospitalization
Hospital days 1-2
On/after hospital day 3
Unknown

Severity of illness
16. Was the patient in an ICU at any time during the hospitalization? Yes
No
Unknown
If Yes, enter the dates of the first ICU admission during the hospitalization:
ICU admission date: ____ / ____ /____
ICU discharge date: ____ / ____ /____
17. Complete the table below for the specified dates (for all events regardless of response to Q.16):
SIRS parameter category

Hospital admission:

First day of vancomycin:

Discharge:

____ / ____ / ____

____ / ____ / ____

____ / ____ / ____

Temperature:
Highest temperature recorded:

____

°C or

°F or

Unk

____

°C or

°F or

Unk

____

°C or

°F or

Unk

Lowest temperature recorded:

____

°C or

°F or

Unk

____

°C or

°F or

Unk

____

°C or

°F or

Unk

Heart rate:
Highest heart rate recorded:

____ bpm or

Unk

____ bpm or

Unk

____ bpm or

Unk

Lowest heart rate recorded:

____ bpm or

Unk

____ bpm or

Unk

____ bpm or

Unk

Highest respiratory rate recorded:

____ bpm or

Unk

____ bpm or

Unk

____ bpm or

Unk

Lowest arterial PaCO2 recorded:

____ mmHg or

Respiratory:

Mechanically ventilated:

Yes

Unk

No

____ mmHg or

Unknown

Yes

Unk

No

____ mmHg or

Unknown

Yes

Unk

No

Unknown

White blood cells:
Highest WBC count recorded:

________ cells/mm3 or
3

Lowest WBC count recorded:

________ cells/mm or

Highest %bands recorded:

____ % or

Unk
Unk

Unk

________ cells/mm3 or
3

________ cells/mm or
____ % or

Unk

________ cells/mm3 or

Unk

Unk

________ cells/mm3 or

Unk

Unk

____ % or

Unk

Blood pressure:
Lowest systolic blood pressure:

____ mmHg or

Unk

____ mmHg or

Unk

____ mmHg or

Unk

Lowest mean arterial pressure:

____ mmHg or

Unk

____ mmHg or

Unk

____ mmHg or

Unk

On vasopressors
Serum lactate (lactic acid)

Yes

No

________ mg/dL or

Unknown
Unk

Yes

No

________ mg/dL or

Unknown
Unk

Yes

No

Intentionally left blank

Unknown

CDCID: ________________

FQEventForm_v6_20140626

18. Antimicrobial administration: complete the table for all antimicrobials administered during the hospitalization.
Drug name

Start date (mm/dd/yy)
and route
____ / ____ / ____
IV
IM

Oral/enteral
Inhaled

____ / ____ / ____
IV
IM

Oral/enteral
Inhaled

____ / ____ / ____
IV
IM

Oral/enteral
Inhaled

____ / ____ / ____
IV
IM

Oral/enteral
Inhaled

____ / ____ / ____
IV
IM

Oral/enteral
Inhaled

____ / ____ / ____
IV
IM

Oral/enteral
Inhaled

____ / ____ / ____
IV
IM

Oral/enteral
Inhaled

____ / ____ / ____
IV
IM

Oral/enteral
Inhaled

____ / ____ / ____
IV
IM

Oral/enteral
Inhaled

____ / ____ / ____
IV
IM

Oral/enteral
Inhaled

End date (mm/dd/yy)
and route
____ / ____ / ____
IV
IM

Oral/enteral
Inhaled

____ / ____ / ____
IV
IM

Oral/enteral
Inhaled

____ / ____ / ____
IV
IM

Oral/enteral
Inhaled

____ / ____ / ____
IV
IM

Oral/enteral
Inhaled

____ / ____ / ____
IV
IM

Oral/enteral
Inhaled

____ / ____ / ____
IV
IM

Oral/enteral
Inhaled

____ / ____ / ____
IV
IM

Oral/enteral
Inhaled

____ / ____ / ____
IV
IM

Oral/enteral
Inhaled

____ / ____ / ____
IV
IM

Oral/enteral
Inhaled

____ / ____ / ____
IV
IM

Oral/enteral
Inhaled

Indication
MedProph
SurProph
NonInfect

Treatment 
Unknown

MedProph
SurProph
NonInfect

Treatment 
Unknown

MedProph
SurProph
NonInfect

Treatment 
Unknown

MedProph
SurProph
NonInfect

Treatment 
Unknown

MedProph
SurProph
NonInfect

Treatment 
Unknown

MedProph
SurProph
NonInfect

Treatment 
Unknown

MedProph
SurProph
NonInfect

Treatment 
Unknown

MedProph
SurProph
NonInfect

Treatment 
Unknown

MedProph
SurProph
NonInfect

Treatment 
Unknown

MedProph
SurProph
NonInfect

Treatment 
Unknown

If treatment: BJI
BSI
CNS
CVI
ENT
GTI
HEB
IAB
LRI
PNEU
REP
UND
UTI
SSI (site): _____________
Other: ______________________
If treatment: BJI
BSI
CNS
CVI
ENT
GTI
HEB
IAB
LRI
PNEU
REP
UND
UTI
SSI (site): _____________
Other: ______________________
If treatment: BJI
BSI
CNS
CVI
ENT
GTI
HEB
IAB
LRI
PNEU
REP
UND
UTI
SSI (site): _____________
Other: ______________________
If treatment: BJI
BSI
CNS
CVI
ENT
GTI
HEB
IAB
LRI
PNEU
REP
UND
UTI
SSI (site): _____________
Other: ______________________
If treatment: BJI
BSI
CNS
CVI
ENT
GTI
HEB
IAB
LRI
PNEU
REP
UND
UTI
SSI (site): _____________
Other: ______________________
If treatment: BJI
BSI
CNS
CVI
ENT
GTI
HEB
IAB
LRI
PNEU
REP
UND
UTI
SSI (site): _____________
Other: ______________________
If treatment: BJI
BSI
CNS
CVI
ENT
GTI
HEB
IAB
LRI
PNEU
REP
UND
UTI
SSI (site): _____________
Other: ______________________
If treatment: BJI
BSI
CNS
CVI
ENT
GTI
HEB
IAB
LRI
PNEU
REP
UND
UTI
SSI (site): _____________
Other: ______________________
If treatment: BJI
BSI
CNS
CVI
ENT
GTI
HEB
IAB
LRI
PNEU
REP
UND
UTI
SSI (site): _____________
Other: ______________________
If treatment: BJI
BSI
CNS
CVI
ENT
GTI
HEB
IAB
LRI
PNEU
REP
UND
UTI
SSI (site): _____________
Other: ______________________

SST

SST

SST

SST

SST

SST

SST

SST

SST

SST

Discharge fluoroquinolone prescribing
19. Was a fluoroquinolone prescribed at discharge (i.e., prescribed to be administered to the patient for additional days after hospital discharge)?
Yes--ciprofloxacin
Yes—levofloxacin
Yes--moxifloxacin
No
Unknown
19b. If yes, what was the route of administration? IV
Oral/enteral Unknown
19c. If yes, enter the duration of the prescription in no. of days:______
Unknown

CDCID: ________________

FQEventForm_v6_20140626

20. Microbiology data during hospitalization: Record tests/cultures collected within 4 days before fluoroquinolone start date through the end date.
4 days before fluoroquinolone start date: ____ / ____ / ____
Fluoroquinolone end date: ____ / ____ / ____

No.

1

2

3

4

5

6

7

8

9

10

Specimen

Blood
Urine
Resp
Other _____
Blood
Urine
Resp
Other _____
Blood
Urine
Resp
Other _____
Blood
Urine
Resp
Other _____
Blood
Urine
Resp
Other _____
Blood
Urine
Resp
Other _____
Blood
Urine
Resp
Other _____
Blood
Urine
Resp
Other _____
Blood
Urine
Resp
Other _____
Blood
Urine
Resp
Other _____

Collect date
(mm/dd/yy)

Test result final
date
(mm/dd/yy)

Positive
or
negative

____/ ___ / ___

____ / ___ / ___

Neg
Pos
Unk

____/ ___ / ___

____ / ___ / ___

____/ ___ / ___

Pathogens
identified
(insert code)

Are all pathogens
susceptible (S) to
≥1 antimicrobial
the patient was
getting THE DAY
AFTER THE TEST
RESULT WAS
FINAL?

Pathogen susceptible
to ciprofloxacin?

Pathogen susceptible
to levofloxacin?

Pathogen susceptible
to moxifloxacin?

Path1______
Path2______
Path3______

Path1:
Path2:
Path3:

Y
Y
Y

N
N
N

U
U
U

Path1:
Path2:
Path3:

Y
Y
Y

N
N
N

U
U
U

Path1:
Path2:
Path3:

Y
Y
Y

N
N
N

U
U
U

Yes
No
Unk

Neg
Pos
Unk

Path1______
Path2______
Path3______

Path1:
Path2:
Path3:

Y
Y
Y

N
N
N

U
U
U

Path1:
Path2:
Path3:

Y
Y
Y

N
N
N

U
U
U

Path1:
Path2:
Path3:

Y
Y
Y

N
N
N

U
U
U

Yes
No
Unk

____ / ___ / ___

Neg
Pos
Unk

Path1______
Path2______
Path3______

Path1:
Path2:
Path3:

Y
Y
Y

N
N
N

U
U
U

Path1:
Path2:
Path3:

Y
Y
Y

N
N
N

U
U
U

Path1:
Path2:
Path3:

Y
Y
Y

N
N
N

U
U
U

Yes
No
Unk

____/ ___ / ___

____ / ___ / ___

Neg
Pos
Unk

Path1______
Path2______
Path3______

Path1:
Path2:
Path3:

Y
Y
Y

N
N
N

U
U
U

Path1:
Path2:
Path3:

Y
Y
Y

N
N
N

U
U
U

Path1:
Path2:
Path3:

Y
Y
Y

N
N
N

U
U
U

Yes
No
Unk

____/ ___ / ___

____ / ___ / ___

Neg
Pos
Unk

Path1______
Path2______
Path3______

Path1:
Path2:
Path3:

Y
Y
Y

N
N
N

U
U
U

Path1:
Path2:
Path3:

Y
Y
Y

N
N
N

U
U
U

Path1:
Path2:
Path3:

Y
Y
Y

N
N
N

U
U
U

Yes
No
Unk

____/ ___ / ___

____ / ___ / ___

Neg
Pos
Unk

Path1______
Path2______
Path3______

Path1:
Path2:
Path3:

Y
Y
Y

N
N
N

U
U
U

Path1:
Path2:
Path3:

Y
Y
Y

N
N
N

U
U
U

Path1:
Path2:
Path3:

Y
Y
Y

N
N
N

U
U
U

Yes
No
Unk

____/ ___ / ___

____ / ___ / ___

Neg
Pos
Unk

Path1______
Path2______
Path3______

Path1:
Path2:
Path3:

Y
Y
Y

N
N
N

U
U
U

Path1:
Path2:
Path3:

Y
Y
Y

N
N
N

U
U
U

Path1:
Path2:
Path3:

Y
Y
Y

N
N
N

U
U
U

Yes
No
Unk

____/ ___ / ___

____ / ___ / ___

Neg
Pos
Unk

Path1______
Path2______
Path3______

Path1:
Path2:
Path3:

Y
Y
Y

N
N
N

U
U
U

Path1:
Path2:
Path3:

Y
Y
Y

N
N
N

U
U
U

Path1:
Path2:
Path3:

Y
Y
Y

N
N
N

U
U
U

Yes
No
Unk

____/ ___ / ___

____ / ___ / ___

Neg
Pos
Unk

Path1______
Path2______
Path3______

Path1:
Path2:
Path3:

Y
Y
Y

N
N
N

U
U
U

Path1:
Path2:
Path3:

Y
Y
Y

N
N
N

U
U
U

Path1:
Path2:
Path3:

Y
Y
Y

N
N
N

U
U
U

Yes
No
Unk

____/ ___ / ___

____ / ___ / ___

Neg
Pos
Unk

Path1______
Path2______
Path3______

Path1:
Path2:
Path3:

Y
Y
Y

N
N
N

U
U
U

Path1:
Path2:
Path3:

Y
Y
Y

N
N
N

U
U
U

Path1:
Path2:
Path3:

Y
Y
Y

N
N
N

U
U
U

Yes
No
Unk

***FORM IS COMPLETE***