Form CDC 57.206 CDC 57.206 Healthcare Worker Prophylaxis/Treatment

The National Healthcare Safety Network (NHSN)

57.206_HCWPEP_BLANK

57.206 Healthcare Worker Prophylaxis/Treatment

OMB: 0920-0666

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Form Approved

OMB No. 0920-0666

Exp. Date: xx/xx/20xx

www.cdc.gov/nhsn

Healthcare Worker Prophylaxis/Treatment

BBF Postexposure Prophylaxis (PEP)


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*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

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