Form Phase 4_PIF_201412 Phase 4_PIF_201412 Patient Information Form (PIF)

Form Approved
OMB No. 0920-0852
Exp. Date 12/31/2016

HAI & ANTIMICROBIAL USE PREVALENCE SURVEY
PATIENT INFORMATION FORM

-

CDC ID:

/

Survey date:

If data collected on survey date, enter data collection time:
OR

/

Data collector initials: _____

:

am

pm

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: _______

Gender:

yrs

M

mos

F

dys

Unknown

Unknown

/

Admission date:

/

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 _______ kilograms OR
Weight unknown
IV. Devices
Urinary catheter:
Central line:

No

No
Yes

Yes

Unknown

Unknown

Ventilator:

No

If “Yes,” indicate how many lines:

Yes

Unknown

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
No

Yes
Yes

Unknown
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
required to respond to
a collection
information unless itSURVEY:
displays a currently
valid OMB
Control Number. Send
2011
HAI is¬
ANTIMICROBIAL
USE
POINTof PREVALENCE
EIP TEAM
ANTIMICROBIAL
USEcomments
FORM 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 (0920-0852).
Phase 4_PIF_ 20141218

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HAI & ANTIMICROBIAL USE 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:

/

/

/

Patient outcome at time of hospital discharge:

OR check one:
Survived

Died

Unknown

Unknown

Still in hospital

Still in hospital

FORM IS COMPLETE

Phase 4_PIF_ 20141218

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