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pdfPatient ID: _____ _____ _____ _____ _____ _____ _____ _____
– ACTIVE BACTERIAL CORE SURVEILLANCE CASE REPORT –
Phone No.: (
Patient's Name:
(Last, First, M.I.)
Address:
)
Patient
Chart No.:
(Number, Street, Apt. No.)
Hospital:
(Zip Code)
(City, State)
– Patient identifier information is NOT transmitted to CDC –
DEPARTMENT OF
HEALTH & HUMAN SERVICES
CENTERS FOR DISEASE CONTROL
AND PREVENTION
ATLANTA, GA 30333
INVASIVE METHICILLIN-RESISTANT • STAPHYLOCOCCUS AUREUS
ACTIVE BACTERIAL CORE SURVEILLANCE (ABCs) CASE REPORT – 2014
Form Approved OMB No. 0920-0978
– SHADED AREAS BELOW INDICATE CORE VARIABLES –
1. STATE:
2. COUNTY:
(Residence of patient)
(Residence of Patient)
3. STATE I.D.:
6. DATE OF BIRTH:
5. SEX:
1
Male
2
Female
Mo.
Day
4a. HOSPITAL/LAB I.D. WHERE
CULTURE IDENTIFIED:
8. STERILE SITE(S) FROM WHICH MRSA WAS INITIALLY
ISOLATED: (Check all that apply)
1
Pericardial fluid
1
Blood
7a. AGE:
Year
7b. Is age in day/mo/yr?
1
Mo.
Day
Days 2
Mos. 3
Yrs.
Year
1
Yes
2
No
9
1
CSF
1
Pleural fluid
1
Bone
1
Peritoneal fluid
1
Muscle
1
Unknown
Day
Yes (HO-MRSA case) 2
1
Hispanic or Latino
12c. WEIGHT: 1
2
Not Hispanic or Latino
9
_______ lbs _______ oz OR _______ kg
Unknown
1
1
1
12e. BMI: 1
Black or
African American
American Indian
or Alaska Native
Asian
1
Native Hawaiian
or Other Pacific Islander
1
Unknown
Unknown
_______ ft _______ in OR _______ cm
12b. RACE: (Check all that apply)
1
White
Unknown
1
6
7
2
3
5
13
14
9
10
LTCF
LTACH
Autopsy
Unknown
Other
Observational Unit/Clinical Decision Unit
16
18. PATIENT OUTCOME:
1
Survived
9
Unknown
Mo.
Day
______________________
No (Complete CRF, CA-MRSA or HACO-MRSA case)
No (STOP data abstraction)
15. Where was the patient located on the
4th calendar day prior to the date of initial culture?
Pregnant
1
Private Residence
2
Post-partum
1
Long Term Care Facility
3
Neither
1
Long Term Acute Care Hospital
1
Homeless
Unknown
14. If case is ≤12 months of age,
type of birth hospitalization:
1
2
NICU/SCN
9
Unknown
1
Incarcerated
1
Hospital Inpatient
1
Other __________________________
1
Unknown
Well Baby Nursery
17. Were cultures of the SAME or OTHER sterile site(s) positive within 30 days after initial culture date?
16. LOCATION OF CULTURE COLLECTION: (Check one)
Outpatient
8
Clinic/
ICU
Doctors Office
Surgery/OR
Surgery
11
Radiology
15
Dialysis/Renal Clinic
Other Unit
Other
4
Outpatient
Emergency Room
Other sterile site (specify)
1
9
_______ (do not calculate, only if available in the MR)
Hospital Inpatient
_____________________
1
Yes (Complete CRF) 2
13. At time of first positive
culture, patient was:
Unknown
12d. HEIGHT: 1
Internal body site (specify)
If yes, was the case selected for full CRF based on
sampling frame 1:10?
Year
1
12a. ETHNIC ORIGIN:
1
11. WAS CULTURE COLLECTED >3 CALENDAR DAYS
AFTER HOSPITAL ADMISSION?
If YES: Date of admission
Mo.
Joint/Synovial fluid
1
10. WAS THE PATIENT HOSPITALIZED AT THE TIME OF,
OR WITHIN 30 CALENDAR DAYS AFTER, INITIAL CULTURE?
9. DATE OF INITIAL CULTURE:
4b. HOSPITAL I.D. WHERE PATIENT TREATED:
1
Yes
2
No
9
Unknown
If yes, indicate site and date of last positive culture:
1
Blood, Date:________
1
Pericardial fluid, Date:________
1
CSF, Date:________
1
Joint/Synovial fluid, Date:________
1
Pleural fluid, Date:________
1
Bone, Date:________
1
Peritoneal fluid, Date:________
1
Muscle, Date:______
2
Year
Died
Mo.
Day
1
Internal body site
Date:________
1
Other sterile site
(specify)____________
Date:________
Year
Date of death
Date of discharge
1
Yes 2
No
If survived, was the patient transferred to a LTACH? 1
Yes 2
No
If survived, was the patient transferred to a LTCF?
Was MRSA cultured from a normally sterile site < calendar day 7 before death?
1
Yes 2
No 9
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 OMBcontrol 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 Reports Clearance Officer; 1600 Clifton Road NE, MS E-11, Atlanta, Georgia 30333; ATTN: PRA (0920-0978)
– IMPORTANT – PLEASE COMPLETE THE BACK OF THIS FORM –
Page 1 of 2
19. TYPES OF MRSA INFECTION ASSOCIATED WITH CULTURE(S): (Check all that apply)
1
None
1
Unknown
1
Abscess (not skin)
1
Cellulitis
1
Meningitis
1
Septic Emboli
1
Traumatic Wound
1
AV Fistula/Graft Infection
1
Chronic Ulcer/Wound (non-decubitus)
1
Peritonitis
1
Septic Shock
1
Urinary Tract
1
Bacteremia
1
Decubitus/Pressure Ulcer
1
Pneumonia
1
Skin Abscess
1
1
Bursitis
1
Empyema
1
Osteomyelitis
1
Surgical Incision
_______________________
1
Catheter Site Infection
1
Endocarditis
1
Septic Arthritis
1
Surgical Site (Internal)
_______________________
20. UNDERLYING CONDITIONS: (Check all that apply) (if none or no chart available, check appropriate box)
1
None
1
Other: (specify)
Unknown
Abscess/Boil (Recurrent)
1
Connective Tissue Disease
1
Hemiplegia/Paraplegia
1
Other Drug Use
1
AIDS
1
Current Smoker
1
HIV
1
Peptic Ulcer Disease
1
Chronic Cognitive Deficit
1
CVA/Stroke
1
1
Peripheral Vascular Disease (PVD)
1
Chronic Liver Disease
1
Cystic Fibrosis
Influenza
(within 10 days of initial culture)
1
Chronic Pulmonary Disease
1
Decubitus/Pressure Ulcer
1
Premature Birth
1
IVDU
1
Chronic Kidney Disease
1
Dementia
1
Metastatic Solid Tumor
1
Chronic Skin Breakdown
1
Diabetes
1
1
1
Congestive Heart Failure
Hematologic Malignancy
1
Myocardial Infarct
1
Obesity
21. PRIOR HEALTHCARE EXPOSURE – Healthcare-associated and Community-associated: (Check all that apply)
1
Previous documented MRSA infection or colonization
Month
Year
OR previous STATE I.D.:
1
Hospitalized within year before initial culture date.
Date of discharge
Mo.
If YES:
Day
Year
1
None
Solid Tumor (non metastatic)
1
Other: (specify only for cases ≤ 12 months
of age) _____________________________
1
Unknown
Surgery within year before initial culture date.
If yes, list the surgeries and dates of surgery that occurred within 90 days prior to the initial culture:
If YES:
1
1
1
Unknown
Date
Surgery
1. __________________________________________
_____/ _____ / _____
2. __________________________________________
_____/ _____ / _____
3. __________________________________________
_____/ _____ / _____
4. __________________________________________
_____/ _____ / _____
1
Dialysis within year before initial culture date.
(Hemodialysis or Peritoneal dialysis)
1
Current chronic dialysis
Peritoneal
Type
Unknown
Hemodialysis
Type of vascular access
AV fistula / graft
Hemodialysis CVC
Unknown
1
Residence in a long-term care facility
within year before initial culture date.
1
Admitted to a LTACH within year
before initial culture date.
1
Central vascular catheter in place at
any time in the 2 calendar days prior
to initial culture.
– THIS SHADED AREA FOR OFFICE USE ONLY –
22. Was case first
identified through
audit?
1
Yes 2
9
Unknown
No
23. CRF status:
1
2
3
4
Complete
Incomplete
Edited & Correct
Chart unavailable
after 3 requests
24. Does this case have
recurrent MRSA
disease?
1
Yes 2
9
Unknown
If YES, previous
(1st) STATE I.D.:
No
25. Date reported to EIP site:
Mo.
Day
26. Initials of
S.O:
Year
27 COMMENTS:_______________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________________________
CDC 52.15B Rev. 9-2013
CS243032
Page 2 of 2
| File Type | application/pdf |
| File Title | 243032_MRSA2013_OMB-1_v14 |
| Author | bjb1 |
| File Modified | 2014-02-19 |
| File Created | 2013-12-18 |