Form CDC 57.206 CDC 57.206 Healthcare Worker Prophylaxis/Treatment

Form Approved

OMB No. 0920-0666

Exp. Date: xx/xx/20xx

www.cdc.gov/nhsn

Healthcare Worker Prophylaxis/Treatment

BBF Postexposure Prophylaxis (PEP)

Page 1 of 2			*required for saving						**required for completion
Facility ID#: ______________________					Med Admin ID#: __________________________
*HCW ID#: ______________________
HCW Name, Last: ______________________				First: _____________________			Middle:_____________________
*Gender: □ F □ M □Other					*Date of Birth: ____ /____ /_______
*Infectious Agent: ______________________					*Exposure Event #: ________________________
Initial Postexposure Prophylaxis
Indication: Prophylaxis					*Time between exposure and first dose: _______ hours
*Drug: ________________		*Drug: ________________			*Drug: ________________			*Drug: ________________
*Date Started: ____ /____ /_______					*Date Stopped: ____ /____ /_______
*Reason for Stopping (select one):
□ Completion of drug therapy			□ Source patient was HIV negative			□ Adverse reactions
□ Lab results			□ HCW choice			□ Possible anti-retroviral resistance
□ Lost to follow up
PEP Change 1	Indicate any change from initial PEP
Indication: Prophylaxis
**Drug: ________________		**Drug: ________________			**Drug: ________________			**Drug: ________________
**Date Started: ____ /____ /_______					**Date Stopped: ____ /____ /_______
**Reason for Stopping (select one):
□ Completion of drug therapy			□ Source patient was HIV negative			□ Adverse reactions
□ Lab results			□ HCW choice			□ Possible anti-retroviral resistance
□ Lost to follow up
PEP Change 2	Indicate any change from initial PEP
Indication: Prophylaxis
**Drug: ________________		**Drug: ________________			**Drug: ________________			**Drug: ________________
**Date Started: ____ /____ /_______					**Date Stopped: ____ /____ /_______
**Reason for Stopping: ____________________________________________________________
□ Completion of drug therapy			□ Source patient was HIV negative			□ Adverse reactions
□ Lab results			□ HCW choice			□ Possible anti-retroviral resistance
□ Lost to follow up
Adverse Reactions
(select all that apply)
□ Abdominal pain		□ Flank pain			□ Loss of appetite			□ Numbness in extremities
□ Arthralgia		□ Headache			□ Lymphadenopathy			□ Paresthesia
□ Dark urine		□ Insomnia			□ Malaise/fatigue			□ Rash
□ Diarrhea		□ Involuntary weight loss			□ Myalgia			□ Somnolence
□ Dizziness		□ Jaundice			□ Nausea			□ Spleen enlargement
□ Emotional distress		□ Light stools			□ Nephrolithiasis			□ Vomiting
□ Fever		□ Liver enlargement			□ Night sweats			□ Other (specify)
								□ Unknown
Assurance of Confidentiality: The voluntarily provided information obtained in this surveillance system that would permit identification of any individual or institution is collected with a guarantee that it will be held in strict confidence, will be used only for the purposes stated, and will not otherwise be disclosed or released without the consent of the individual, or the institution in accordance with Sections 304, 306 and 308(d) of the Public Health Service Act (42 USC 242b, 242k, and 242m(d)). Public reporting burden of this collection of information is estimated to average 15 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, Reports Clearance Officer, 1600 Clifton Rd., MS D-74, Atlanta, GA 30333, ATTN: PRA (0920-0666). CDC 57.206 (Front), v6.6

Healthcare Worker Prophylaxis/Treatment

Page 2 of 2
Custom Fields
Label		Label
_________________________	____/____/_____	_______________________	____/____/_____
_________________________	______________	_______________________	______________
_________________________	______________	_______________________	______________
_________________________	______________	_______________________	______________
_________________________	______________	_______________________	______________
_________________________	______________	_______________________	______________
_________________________	______________	_______________________	______________
Comments