Patient Information Form

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

2014 HAI & ANTIMICROBIAL USE POINT PREVALENCE SURVEY

Form Approved

OMB No. 0920-XXX

Exp. Date xx/xx/20xx

PATIENT INFORMATION FORM

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

If data collected on survey date, enter data collection time: : am pm

OR Data collection done retrospectively

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. Demographic information
Age: _______ yrs mos dys Unknown		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/other Pacific Islander Asian	White Other race Unknown		Ethnicity: Hispanic or Latino Not Hispanic or Latino Unknown	Primary Payer: Medicare Medicaid Private insurance	Self-pay No charge Other Unknown

III. Weight and height

For infants in neonatal locations (e.g., CC-NURS, CCS-NURS, S-NURS, W-NURS, W-LDRP):

Birthweight: _______ pounds _______ ounces OR _______ grams OR Birthweight unknown

For other patients:

BMI: _______ OR Unknown (if BMI unknown, enter Height and Weight below)

Height: _______ feet _______ inches OR _______ cm OR Height unknown

Weight: _______ pounds _______ ounces OR _______ grams OR Weight unknown

IV. Devices
Urinary catheter: No Yes Unknown	Ventilator: No Yes Unknown
Central line: No Yes Unknown If “Yes,” indicate how many lines: 1 line >1 line Unknown

V. Antimicrobials
Antimicrobials administered or scheduled to be administered: On the survey date: On the day before the survey date:	No Yes Unknown No Yes Unknown

Public reporting burden of this collection of information is estimated to average 17 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 Information Collection Request Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-XXXX).

2011 HAI & ANTIMICROBIAL USE POINT PREVALENCE SURVEY: EIP TEAM ANTIMICROBIAL USE FORM

Form Approved

OMB No. 0920-XXXX

Exp. Date xx/xx/20xx

Form Approved

OMB No. 0920-XXXX

Exp. Date xx/xx/20xx

2014 HAI & ANTIMICROBIAL USE POINT PREVALENCE SURVEY

PATIENT INFORMATION FORM

Page 2

CDC ID: - Data collector initials: _____

VI. Follow-up information

Enter date of follow-up data collection: //

Hospital discharge date: // OR check one: Unknown Still in hospital

Patient outcome at time of hospital discharge: Survived Died Unknown Still in hospital

FORM IS COMPLETE

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