Residents by Location Form

Form Approved

OMB No. 0920-XXXX

Exp. Date xx/xx/20xx

Residents by Location Form

Section A: for all residents on the day of the survey

Section B: only complete if response to 4 = Y For 8 to 18 Write Y if the condition is TRUE ON THE DAY OF THE SURVEY

Section C: To be completed by NH Team Lead or EIP Team

CDC Resident ID

For local use, will not be transmitted to CDC

Admission date, mm/dd/yyyy

Present in the facility

Age in years

Race

Ethnicity

Male gender

Short stay

Diabetes

Receiving dialysis

Wheelchair bound or bedridden

INDWELLING urinary catheter (Foley)

Use of other urinary device (not a Foley)

Central line

Tracheostomy tube

Ventilator

Percutaneous Gastrostomy/ Jejunostomy (PEG/PEJ) tube

Pressure ulcer

Receiving wound care

Receiving systemic antimicrobial(s)

Condition that may indicate presence of infection

If 20a = Y, condition(s) present

Room, bed number

Resident name

1

2

3

4

5

6a

6b

7

8

9

10

11

12a

12b

13

14

15

16

17

18

19

20a

20b

XX-XX-001

XX-XX-002

XX-XX-003

XX-XX-004

XX-XX-005

XX-XX-006

XX-XX-007

XX-XX-008

XX-XX-009

XX-XX-010

6a. Race response options: American Indian or Alaska Native, Asian, Black or African American, Native Hawaiian/Other Pacific Islander, White 6b. Ethnicity response options: Hispanic/Latino , Not Hispanic/Latino 20b. Only complete if 20a=Y. Use the instructions to indicate which conditions are present

Public reporting burden of this collection of information is estimated to average 15 minutes per response (one row) or 150 minutes for all 10 rows, 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).

Facility ID: ____- ____ Survey Date: _____________ Data Collectors Initials: ____________

location name: ______________ Location Type: ____________ Total beds (occupied + non-occupied): _____

Last Revision: 02.02.2016