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pdf– ACTIVE BACTERIAL CORE SURVEILLANCE CASE REPORT –
Patient’s Name:
Phone No.: (
Patient
Chart No.:
(Last, First, MI.)
Address:
(Number, Street, Apt. No.)
(City, State)
)
Hospital:
(Zip Code)
er information is not transmitted to CDC –
2015 Active Bacterial Core
Surveillance (ABCs) CASE REPORT
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR DISEASE CONTROL
AND PREVENTION
ATLANTA, GA 30333
A CORE
COMPONENT OF THE EMERGING INFECTIONS PROGRAM NETWORK
OMB No. 0920-0978
– SHADED AREAS FOR OFFICE USE ONLY –
1. STATE:
(Residence of Patient)
2. STATE I.D.:
3. DATE FIRST POSITIVE CULTURE COLLECTED
(Date Specimen Collected)
Mo.
Day
Mo.
Day
Year
9a. AGE:
8. DATE OF BIRTH:
Day
10. SEX:
Year
9b. Is age in day/mo/yr?
1
Days 2
Mos. 3
1
Male
1
Hispanic or Latino
2
Female
2
Not Hispanic or Latino
9
Unknown
12a. BACTERIAL SPECIES ISOLATED FROM ANY NORMALLY STERILE SITE:
Neisseria meningitidis
3
Group B Streptococcus
2
Haemophilus influenzae
4
Listeria monocytogenes 6
1
Bone
Blood
1
Peritoneal fluid
1
CSF
1
Pericardial fluid 1
1
Other normally sterile site (specify)______________________________________ 1
Muscle/Fascia/Tendon 1
1
Yes
2
If YES, date of admission:
Day
White
1
Asian
1
Black
1
1
American Indian
or Alaska Native 1
Native Hawaiian
or Other Pacific Islander
Date of discharge:
Year
Mo.
Placenta
1
Wound
1
Amniotic fluid
1
Middle ear
No 9
Unknown
Internal body site (specify) _____________
Day
1
Yes 2
1
No
Yes
2
No
9
18b. If resident of a facility, what 19a.Was patient transferred
from another hospital?
was the name of the facility?
Private residence
4
Homeless
7
Non-medical ward
2
Long term care facility
5
Incarcerated
8
Other(specify) ____________
1
Yes 2
Unknown
9
Unknown
College dormitory 9
20a. WEIGHT:
19b. If YES, hospital I.D.:
No
21. TYPE OF INSURANCE: (Check all that apply)
______lbs______ oz OR ______ kg
OR
Unknown
______ft ______ in OR ______ cm OR
Unknown
20b. HEIGHT:
20c. BMI:
___ ___ . ___
22. OUTCOME: 1
Sinus
Unknown
1
Long term acute care facility 6
1
17. If patient was hospitalized, was this patient admitted to the
ICU during hospitalization?
Year
18a. Where was the patient a resident at time of initial culture?
3
Unknown
1
Pleural fluid
INFLUENZA 15. Did this patient have a positive flu test 10 days prior to or following any
_____________ ABCs positive culture?
Mo.
1
14. OTHER SITES FROM WHICH ORGANISM
ISOLATED: (Check all that apply)
Joint
1
16. WAS PATIENT
HOSPITALIZED?
Chart unavailable
after 3 requests
Streptococcus pneumoniae
13. STERILE SITES FROM WHICH ORGANISM ISOLATED: (Check all that apply)
1
Incomplete 4
12b. OTHER BACTERIAL SPECIES ISOLATED FROM ANY NORMALLY STERILE SITE:
(specify)
Group A Streptococcus
5
1
Complete
2
11b. RACE: (Check all that apply)
11a. ETHNIC ORIGIN:
Yrs.
Edited & Correct
3
1
7b. HOSPITAL I.D. WHERE
PATIENT TREATED:
7a. HOSPITAL/LAB I.D. WHERE
CULTURE IDENTIFIED:
6. COUNTY:
(Residence of Patient)
Mo.
5. CRF Status:
4. Date reported to EIP site:
Year
OR
Died 9
24a. At time of first positive culture,
patient was:
2
Postpartum 9
1
Military
1
Other(specify) _________________
1
Medicare
1
Indian Health Service (IHS)
1
Uninsured
1
Medicaid/state assistance program
1
Incarcerated
1
Unknown
23. If patient died, was the culture obtained on autopsy?
Unknown
24b. If pregnant or postpartum, what was the outcome of fetus:
Neither
3
Pregnant
Private
Unknown
Survived 2
1
1
Unknown
1
Survived, no apparent illness 4
Abortion/stillbirth 9
2
Survived, clinical infection
5
Induced abortion
3
Live birth/neonatal death
6
Still pregnant
Unknown
1
Yes 2
No 9
Unknown
25. If patient <1 month of age, indicate gestational age
and birth weight. If pregnant, indicate gestational
age of fetus, only.
Birth weight:
Gestational age:
(wks)
(gms)
26. TYPES OF INFECTION CAUSED BY ORGANISM: (Check all that apply)
1
1
1
Bacteremia
1
without Focus
1
Meningitis
Otitis media
1
Pneumonia 1
Cellulitis
Epiglottitis
1
1
Hemolytic uremic 1
syndrome (HUS)
1
Abscess (not skin)
1
Peritonitis
Pericarditis
1
Septic arthritis
1
Endocarditis
1
Necrotizing fasciitis 1
Septic abortion
1
Osteomyelitis
1
Endometritis
1
Puerperal sepsis
Empyema
1
STSS
1
Septic shock
Chorioamnionitis 1
1
Other(specify)
Unknown
Public reporting burden of this collection of information is estimated to average 10 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 information, including suggestions for reducing this burden to CDC,
Do not send the completed form to this address.
CDC 52.15A REV. 10-2014
– ACTIVE BACTERIAL CORE SURVEILLANCE CASE REPORT –
– IMPORTANT – PLEASE COMPLETE THE BACK OF THIS FORM –
Page 1 of 2
27. UNDERLYING CAUSES OR PRIOR ILLNESSES: (Check all that apply OR if NONE or CHART UNAVAILABLE,check appropriate box) 1
1
1
AIDS or CD4 count <200
Alcohol Abuse, Current
1
1
IVDU, Current
1
CSF Leak
1
IVDU, Past
1
1
1
Alcohol Abuse, Past
Asthma
Atherosclerotic Cardiovascular Disease
(ASCVD)/CAD
1
Current Smoker
1
Deaf/Profound Hearing Loss
1
Dementia
1
Diabetes Mellitus
1
1
1
1
1
1
Emphysema/COPD
Heart Failure/CHF
HIV Infection
Hodgkin’s Disease/Lymphoma
Immunoglobulin Deficiency
Immunosuppressive Therapy (Steroids,
Chemotherapy, Radiation)
1
1
1
1
1
1
Leukemia
Multiple Myeloma
Multiple Sclerosis
Nephrotic Syndrome
Neuromuscular Disorder
Obesity
1
1
Parkinson’s Disease
Other Drug Use, Current
1
Other Drug Use, Past
1
Peripheral Neuropathy
Bone Marrow Transplant (BMT)
Cerebral Vascular Accident (CVA)/Stroke
Chronic Kidney Disease
Current Chronic Dialysis
Chronic Skin Breakdown
Cirrhosis/Liver Failure
Cochlear Implant
1
1
1
1
1
1
1
None 1
Unknown
1
1
Plegias/Paralysis
Premature Birth (specify gestational
(wks)
age at birth )
1
1
1
1
1
1
Seizure/Seizure Disorder
Sickle Cell Anemia
Solid Organ Malignancy
Solid Organ Transplant
Splenectomy/Asplenia
Systemic Lupus Erythematosus (SLE)
1
Other prior illness (specify)
– IMPORTANT – PLEASE COMPLETE FOR THE RELEVANT ORGANISM –
HAEMOPHILUS INFLUENZAE
28a. What was the serotype?
1
b
2
Not Typeable
3
1
28b. If <15 years of age and serotype ‘b’ or ‘unknown’ did
patient receive Haemophilus influenzae b vaccine?
DOSE
DATE GIVEN
Mo.
Day
a
4
Yes
c
2
5
d
6
7
No
9
Unknown
f
8
Other (specify)
9
If YES, please complete the list below.
VACCINE NAME
Year
e
LOT NUMBER
MANUFACTURER
Not Tested or Unknown
28c. Were records obtained to verify
vaccination history? (<5 years of age
with Hib/unknown serotype, only)
1
1
Yes
2
No
If YES, what was the source of the
information? (Check all that apply)
2
3
4
NEISSERIA MENINGITIDIS
29. What was the 1
serogroup?
2
A
3
C
5
W135
B
4
Y
6
Not groupable 8
9
30. Is patient currently attending college?
1
31. Did patient receive meningococcal vaccine?
1
DATE GIVEN
Unknown
1
Other
Yes 2
No 9
Unknown
Yes 2
No 9
Unknown
Mo.
Day
VACCINE NAME
Vaccine Registry
1
Healthcare Provider
1
Other(specify)
STREPTOCOCCUS PNEUMONIAE
32. Did patient receive pneumococcal vaccine?
MANUFACTURER
Yes
2
No 9
Unknown
If YES, please note which pneumococcal vaccine was received:
(Check all that apply)
If YES, please complete the following information:
DOSE
1
LOT NUMBER
Year
1
2
®
1
Prevnar , 7-valent Pneumococcal Conjugate Vaccine (PCV7)
1
Prevnar-13 , 13-valent Pneumococcal Conjugate Vaccine (PCV13)
1
®
Pneumovax®, 23-valent Pneumococcal Polysaccharide Vaccine (PPV23)
1
Vaccine type not specified
If between ≥2 months and<5 years of age and an isolate is available for
serotyping, please complete the Invasive Pneumococcal Disease in
Children expanded form.
3
GROUP A STREPTOCOCCUS
(#33–35 refer to the 14 days
prior to first positive culture)
33. Did the patient have surgery
or any skin incision?
1
Yes 2
Mo.
No 9
Day
34. Did the patient deliver a baby (vaginal or C-section) ? 35. Did patient have:
Unknown
1
Yes 2
No 9
Year
Mo.
If YES,
date of delivery:
If YES, date of surgery or skin incision:
Unknown
Day
Year
1
Varicella
1
Penetrating trauma
1
Blunt trauma
1
Surgical wound
(post operative)
1
Burns
If YES to any of the above, record the number of
(if > 1, use the most recent skin injury)
1
0-7 days
2
8-14 days
36. COMMENTS:
– SURVEILLANCE OFFICE USE ON LY –
37. Was case first
1
identified through
audit?
9
Yes 2
Unknown
No
38. Does this case have 1
recurrent disease with
the same pathogen? 9
Yes 2
Unknown
No
39. Initials of
S.O.:
If YES, previous
(1st) state I.D.:
Submitted By:
Phone No. : (
)
Physician’s Name:
Phone No. : (
)
CDC 52.15A REV. 10-2014
– ACTIVE BACTERIAL CORE SURVEILLANCE CASE REPORT –
Date:
/
/
Page 2 of 2
| File Type | application/pdf |
| File Title | ABCs CRF 2013 |
| File Modified | 2014-10-29 |
| File Created | 2012-09-20 |