Undetermined cause of Serratia marcescens infections - M

Confidential

Undetermined cause of Serratia marcescens bloodstream infections - Multiple States, 2018
Page 1 of 13

Undetermined cause of Serratia marcescens infections Multiple States, 2018
Record ID

__________________________________
(NOTE: This is autogenerated by REDCap and does
not need to be completed on paper forms.)

Form Approved
OMB Control No. 0920-XXXX
Exp. date: XX/XX/XXXX
For information on locating lot/catalog numbers for BD products, please click the PDF below. (If using PDF chart
abstraction form, flip to last page.)
[Attachment: "lotnumbers.pdf"]

CDC epi ID

__________________________________
(CDC will complete)

CDC lab ID number

__________________________________
(CDC will complete)

State epi ID

__________________________________
(Please ensure this ID matches any previously
communicated information on this patient.)

State lab ID number

__________________________________
(Please ensure this ID matches any previously
communicated information on this patient.)

Data chart abstraction completed

__________________________________

Case type

Confirmed
Probable

Specimen date

__________________________________
(Date the (+) culture was drawn. If multiple (+)
cultures, include only the first one that matches
an outbreak strain by PFGE.)

Specimen type

Blood
Urine
Sputum
Stool
Tracheal aspirate
Other (specify)
(If more than one specimen type, check the one(s)
corresponding to the PFGE results below.)

Specify other specimen type

__________________________________

Result

__________________________________
(Pathogen identified - may list more than one
pathogen. If multiple specimen types reported
above, please specify which types were (+) for
which pathogen(s).)

Public reporting burden of this collection of information is estimated to average 2 hours per response, including the time for reviewing
instructions, searching existing data sources, gathering and maintaining the data needed, andcompleting and reviewing the collection
of information. An agency may not conduct or sponsor, and a person is notrequired 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/ATSDR Reports Clearance Officer, 1600 Clifton Road NE,
MS D-74, Atlanta, Georgia 30333; ATTN: PRA 0920-XXXX
04/24/2018 9:48am

www.projectredcap.org

Confidential

Form Approved
OMB Control No. 0920-XXXX
Exp. date: XX/XX/XXXX

PFGE
State

Facility ID (primary facility where patient was
receiving care prior to bacteremia diagnoses)

Page 2 of 13

__________________________________
(PFGE pattern designated by the lab)
AL
AK
AZ
AR
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
PR
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
__________________________________
(Unique ID assigned by state (CDC does not collect
facility names))

Public reporting burden of this collection of information is estimated to average 2 hours per response, including the time for reviewing
instructions, searching existing data sources, gathering and maintaining the data needed, andcompleting and reviewing the collection
of information. An agency may not conduct or sponsor, and a person is notrequired 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/ATSDR Reports Clearance Officer, 1600 Clifton Road NE,
MS D-74, Atlanta, Georgia 30333; ATTN: PRA 0920-XXXX
04/24/2018 9:48am

www.projectredcap.org

Confidential

Form Approved
OMB Control No. 0920-XXXX
Exp. date: XX/XX/XXXX

Facility unit type

Page 3 of 13

Acute care facility for pediatric patients
Acute care facility for adult patients
Acute care facility for both pediatric and adult
patients
Outpatient only (including home health, outpatient
clinic, or infusion center)
Other (specify)

Specify other facility type or outpatient setting

__________________________________
((e.g., infusion center))

Facility location

__________________________________
(Location in facility where patient located when
culture drawn (e.g., ER, floor, NICU, PICU, etc.))

Prior to the bacteremia diagnosis did the patient
receive infusions or line care at an additional
facility?
Facility ID number of second facility
Facility unit type

Yes
No
__________________________________
Acute care facility for pediatric patients
Acute care facility for adult patients
Acute care facility for both pediatric and adult
patients
Outpatient only (including home health, outpatient
clinic, or infusion center)
Other (specify)

Specify other facility type or outpatient setting

__________________________________
((e.g., infusion center))

Age (years)

__________________________________
(Patient age at date of positive culture)

Sex

Male
Female
Other

Primary diagnosis (non-Serratia)

__________________________________
(Patient's primary diagnosis prior to becoming
infected with Serratia)

Other diagnoses

__________________________________
(Other medical/surgical diagnoses)

Immunocompromised?

Yes
No
(e.g. was the patient on chemotherapy or high dose
steroids, was there a diagnosis of an immune
disorder such as HIV/AIDS)

What was the patient's outcome?

Died
Still hospitalized
Discharged alive

CVC

Yes
No
(Was a central venous catheter present within 2
days of (+) culture being drawn)

CVC insertion/change date

__________________________________
(Most recent line insertion/change prior to
symptom onset/(+) culture, whichever was first)

Public reporting burden of this collection of information is estimated to average 2 hours per response, including the time for reviewing
instructions, searching existing data sources, gathering and maintaining the data needed, andcompleting and reviewing the collection
of information. An agency may not conduct or sponsor, and a person is notrequired 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/ATSDR Reports Clearance Officer, 1600 Clifton Road NE,
MS
D-74, Atlanta,
04/24/2018
9:48amGeorgia 30333; ATTN: PRA 0920-XXXX
www.projectredcap.org

Confidential Form Approved

OMB Control No. 0920-XXXX
Exp. date: XX/XX/XXXX

CVC type

Page 4 of 13

Tunneled central line
Non-tunneled central line
Implanted port
PICC
Midline
Umbilical
Other
Unknown

Specify other CVC type

__________________________________

Report any other indwelling vascular access in
additional to the central line.

__________________________________

POA/inpatient

Present on admission
Inpatient
(Was the bacteremia present on admission or did
the patient develop this while an inpatient?)

For information on locating lot/catalog numbers for BD products, please click the PDF below. (If using PDF chart
abstraction form, flip to last page.)
[Attachment: "lotnumbers.pdf"]

Public reporting burden of this collection of information is estimated to average 2 hours per response, including the time for reviewing
instructions, searching existing data sources, gathering and maintaining the data needed, andcompleting and reviewing the collection
of information. An agency may not conduct or sponsor, and a person is notrequired 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/ATSDR Reports Clearance Officer, 1600 Clifton Road NE,
MS D-74, Atlanta, Georgia 30333; ATTN: PRA 0920-XXXX

04/24/2018 9:48am

www.projectredcap.org

Confidential Form Approved

OMB Control No. 0920-XXXX
Exp. date: XX/XX/XXXX

Page 5 of 13

This section asks about specific BD SALINE products. If additional saline products were
administered, please add them in the next section.
Adminis Adminis Unable Product Product Product
tered to tered to
to
adminis adminis availabl
patient patient determi tered
tered e on the
< 48
48
ne if
inside outside patient
hours
hours - adminis facility facility
unit
prior to 7 days tered to
prior to
(+)
prior to patient
(+)
culture
(+)
culture
culture

Product Product Product Product
availabl currentl adminis adminis
e in the
y in
tered
tered
facility stock at by hand
by
prior to time of
pump
(+)
public
culture health
investig
ation

(A) BD™ Pre-Filled Normal Saline
Syringe
Volume 10mL; Diameter 10mL
(B) BD™ Pre-Filled Normal Saline
Syringe
Volume 5mL; Diameter 5mL
(C) BD™ Pre-Filled Normal Saline
Syringe
Volume: 3mL; Diameter 10mL
(D) BD™ Pre-Filled Normal Saline
Syringe
Volume: 5mL; Diameter 5mL
(E) BD™ Pre-Filled Normal Saline
Syringe
Volume: 3mL; Diameter 5mL
(F) BD™ Pre-Filled Normal Saline
Syringe
Volume: 3mL; Diameter 3mL
(G) BD™ Pre-Filled Normal Saline
Syringe
Volume: 2mL; Diameter 3mL
(H) BD™ Pre-Filled Normal Saline
Syringe with Blunt Plastic
Cannula
Volume: 10mL; Diameter: 10mL
(I) BD™ Pre-Filled Normal Saline
Syringe with Blunt Plastic
Cannula
Volume: 5mL; Diameter: 10mL

Public reporting burden of this collection of information is estimated to average 2 hours per response, including the time for reviewing
instructions, searching existing data sources, gathering and maintaining the data needed, andcompleting and reviewing the collection
of information. An agency may not conduct or sponsor, and a person is notrequired 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/ATSDR Reports Clearance Officer, 1600 Clifton Road NE,
MS D-74, Atlanta, Georgia 30333; ATTN: PRA 0920-XXXX
04/24/2018 9:48am

www.projectredcap.org

Confidential Form Approved

OMB Control No. 0920-XXXX
Exp. date: XX/XX/XXXX

Page 6 of 13

(J) BD™ Pre-Filled Normal Saline
Syringe with Blunt Plastic
Cannula
Volume: 5mL; Diameter: 5mL
(K) BD™ Pre-Filled Normal Saline
Syringe with Blunt Plastic
Cannula
Volume: 3mL; Diameter: 3mL

Catalog (REF) number

__________________________________
(If multiple products checked above, specify which
catalog number corresponds to which formulation,
e.g.,Catalog (REF) number, A = 306507, B =
306508; Lot number, A = 705311B, B = 706211B, etc.)

Lot number

__________________________________
(If multiple products checked above, specify which
lot number corresponds to which formulation,
e.g., A = 762323; B = 921412; etc.)

Were additional saline products administered within 7 days of the (+) culture? If so, enter the
information below (for up to 3 additional saline products).
Saline flush name

__________________________________
(Name of saline flush product used on this patient
to include manufacturer, sterile field or
non-sterile field)

When was this product used?

< 48 hours prior to (+) culture
48 hours - 7 days prior to (+) culture

Was this product administered inside the facility or
outside the facility?

Inside facility
Outside facility
Both

Was this product administered by hand or using a
pump?

By hand
Pump
Other (specify)

Specify how saline product was administered.

__________________________________

Saline flush concentration

__________________________________
(e.g., 0.9%)

Saline syringe size

__________________________________
(e.g., 10ml)

Saline volume in the syringe

__________________________________
(e.g., 5ml (this would be the total volume of
liquid product in syringe))

Provide catalog (REF) number:

__________________________________

Saline flush lot #

__________________________________
(Lot # if known)

Public reporting burden of this collection of information is estimated to average 2 hours per response, including the time for reviewing
instructions, searching existing data sources, gathering and maintaining the data needed, andcompleting and reviewing the collection
of information. An agency may not conduct or sponsor, and a person is notrequired 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/ATSDR Reports Clearance Officer, 1600 Clifton Road NE,
MS D-74, Atlanta, Georgia 30333; ATTN: PRA 0920-XXXX
04/24/2018 9:48am

www.projectredcap.org

Confidential Form Approved

OMB Control No. 0920-XXXX
Exp. date: XX/XX/XXXX

Page 7 of 13

Does this lot # correspond what was administered to
this patient, available on the patient unit within
the 48 hours prior to symptom onset, available in
the facility within the 48 hours prior to symptom
onset, or currently in stock at the time of public
health investigation?

Administered to patient
Available on the patient unit within the 48 hours
prior to symptom onset
Available in the facility within 48 hours prior to
symptom onset
Currently in stock at the time of public health
investigation
(Please check the most specific option (i.e., if
used on this specific patient and used on the
unit, check "used on this patient."))

Saline flush name 2

__________________________________
(Name of saline flush product used on this patient
to include manufacturer, sterile field or
non-sterile field)

When was this product used?

< 48 hours prior to (+) culture
48 hours - 7 days prior to (+) culture

Was this product administered inside the facility or
outside the facility?

Inside facility
Outside facility
Both

Was this product administered by hand or using a
pump?

By hand
Pump
Other (specify)

Specify how saline was administered.

__________________________________

Saline flush concentration 2

__________________________________
(e.g., 0.9%)

Saline syringe size 2

__________________________________
(e.g., 10ml)

Saline volume in the syringe 2

__________________________________
(e.g., 5ml (this would be the total volume of
liquid product in syringe))

Provide catalog (REF) number:

__________________________________

Saline flush lot # 2

__________________________________
(Lot # if known)

Does this lot # correspond to what was administered
to this patient, available on the patient unit
within the 48 hours prior to symptom onset,
available in the facility within the 48 hours prior
to symptom onset, or currently in stock at the time
of public health investigation?

Administered to patient
Available on the patient unit within the 48 hours
prior to symptom onset
Available in the facility within 48 hours prior to
symptom onset
Currently in stock at the time of public health
investigation
(Please check the most specific option (i.e., if
used on this specific patient and used on the
unit, check "used on this patient."))

Public reporting burden of this collection of information is estimated to average 2 hours per response, including the time for reviewing
instructions, searching existing data sources, gathering and maintaining the data needed, andcompleting and reviewing the collection
of information. An agency may not conduct or sponsor, and a person is notrequired 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/ATSDR Reports Clearance Officer, 1600 Clifton Road NE,
MS D-74, Atlanta, Georgia 30333; ATTN: PRA 0920-XXXX

04/24/2018 9:48am

www.projectredcap.org

Confidential Form Approved

OMB Control No. 0920-XXXX
Exp. date: XX/XX/XXXX

Saline flush name 3

Page 8 of 13

__________________________________
(Name of saline flush product used on this patient
to include manufacturer, sterile field or
non-sterile field)

When was this product used?

< 48 hours prior to (+) culture
48 hours - 7 days prior to (+) culture

Was this product administered inside the facility or
outside the facility?

Inside facility
Outside facility
Both

Was this product administered by hand or using a
pump?

By hand
Pump
Other (specify)

Specify how saline was administered.

__________________________________

Saline flush concentration 3

__________________________________
(e.g., 0.9%)

Saline syringe size 3

__________________________________
(e.g., 10ml)

Saline volume in the syringe 3

__________________________________
(e.g., 5ml (this would be the total volume of
liquid product in syringe))

Provide catalog (REF) number:

__________________________________

Saline flush lot # 3

__________________________________
(Lot # if known)

Does this lot # correspond to what was administered
to this patient, available on the patient unit
within the 48 hours prior to symptom onset,
available in the facility within the 48 hours prior
to symptom onset, or currently in stock at the time
of public health investigation?

Administered to patient
Available on the patient unit within the 48 hours
prior to symptom onset
Available in the facility within 48 hours prior to
symptom onset
Currently in stock at the time of public health
investigation
(Please check the most specific option (i.e., if
used on this specific patient and used on the
unit, check "used on this patient."))

For information on locating lot/catalog numbers for BD products, please click the PDF below. (If using PDF chart
abstraction form, flip to last page.)
[Attachment: "lotnumbers.pdf"]

Public reporting burden of this collection of information is estimated to average 2 hours per response, including the time for reviewing
instructions, searching existing data sources, gathering and maintaining the data needed, andcompleting and reviewing the collection
of information. An agency may not conduct or sponsor, and a person is notrequired 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/ATSDR Reports Clearance Officer, 1600 Clifton Road NE,
MS D-74, Atlanta, Georgia 30333; ATTN: PRA 0920-XXXX
04/24/2018 9:48am

www.projectredcap.org

Confidential Form Approved

OMB Control No. 0920-XXXX
Exp. date: XX/XX/XXXX

Page 9 of 13

This section asks about specific BD HEPARIN products. If additional heparin products were
administered, please add them in the next section.
Adminis Adminis Unable Product Product Product
tered to tered to
to
adminis adminis availabl
patient patient determi tered
tered e on the
< 48
48
ne if
inside outside patient
hours
hours - adminis facility facility
unit
prior to 7 days tered to
prior to
(+)
prior to patient
(+)
culture
(+)
culture
culture

Product Product Product Product
availabl currentl adminis adminis
e in the
y in
tered
tered
facility stock at by hand
by
prior to time of
pump
(+)
public
culture health
investig
ation

(A) BD PosiFlush™ Heparin Lock
Flush Syringe 10units/mL
Volume: 6mL; Diameter: 10mL

(B) BD PosiFlush™ Heparin Lock
Flush Syringe 10units/mL
Volume: 5mL; Diameter: 10mL

(C) BD PosiFlush™ Heparin Lock
Flush Syringe 10units/mL
Volume: 3mL; Diameter: 10mL

(D) BD PosiFlush™ Heparin Lock
Flush Syringe 10units/mL
Volume: 5mL; Diameter: 5mL

(E) BD PosiFlush™ Heparin Lock
Flush Syringe 10units/mL
Volume: 3mL; Diameter: 3mL

(F) BD PosiFlush™ Heparin Lock
Flush Syringe with Blunt Plastic
Cannula 10 units/mL
(G) BD PosiFlush™ Heparin Lock
Flush Syringe 100 units/mL
Volume: 5mL; Diameter: 10mL

(H) BD PosiFlush™ Heparin Lock
Flush Syringe 100 units/mL
Volume: 3mL; Diameter: 10mL

Public reporting burden of this collection of information is estimated to average 2 hours per response, including the time for reviewing
instructions, searching existing data sources, gathering and maintaining the data needed, andcompleting and reviewing the collection
of information. An agency may not conduct or sponsor, and a person is notrequired 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/ATSDR Reports Clearance Officer, 1600 Clifton Road NE,
MS D-74, Atlanta, Georgia 30333; ATTN: PRA 0920-XXXX
04/24/2018 9:48am

www.projectredcap.org

Confidential Form Approved

OMB Control No. 0920-XXXX
Exp. date: XX/XX/XXXX

Page 10 of 13

(I) BD PosiFlush™ Heparin Lock
Flush Syringe 100 units/mL
Volume: 5mL; Diameter: 5mL

(J) BD PosiFlush™ Heparin Lock
Flush Syringe 100 units/mL
Volume: 3mL; Diameter: 5mL

(K) BD PosiFlush™ Heparin Lock
Flush Syringe 100 units/mL
Volume: 3mL; Diameter: 3mL

(L) BD PosiFlush™ Heparin Lock
Flush Syringe 100 units/mL
Volume: 2mL; Diameter: 3mL

(M) BD PosiFlush™ Heparin Lock
Flush Syringe with Blunt Plastic
Cannula 100 units/mL
Catalog (REF) number

__________________________________
(If multiple products checked above, specify which
catalog number corresponds to which formulation,
e.g., Catalog (REF) number, A = 306507, B =
306508; Lot number, A = 705311B, B = 706211B, etc.)

Lot number

__________________________________
(If multiple products checked above, specify which
lot number corresponds to which formulation,
e.g., A = 762323; B = 921412; etc.)

Were additional heparin products administered within 7 days of (+) culture? If so, enter the
information below (for up to 3 additional heparin products).
Heparin flush name

__________________________________
(name and of the heparin product to include
manufacturer, sterile field or not, etc.)

When was this product used?

< 48 hours prior to (+) culture
48 hours - 7 days prior to (+) culture

Was this product administered inside the facility or
outside the facility?

Inside facility
Outside facility
Both

Was this product administered by hand or using a
pump?

By hand
Pump
Other (specify)

Specify how heparin was administered.

__________________________________

Heparin concentration

__________________________________
(typically given in units/ml such as 10u/ml or
100u/ml)

Public reporting burden of this collection of information is estimated to average 2 hours per response, including the time for reviewing
instructions, searching existing data sources, gathering and maintaining the data needed, andcompleting and reviewing the collection
of information. An agency may not conduct or sponsor, and a person is notrequired 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/ATSDR Reports Clearance Officer, 1600 Clifton Road NE,
MS D-74, Atlanta, Georgia 30333; ATTN: PRA 0920-XXXX

04/24/2018 9:48am

www.projectredcap.org

Confidential Form Approved

OMB Control No. 0920-XXXX
Exp. date: XX/XX/XXXX

Page 11 of 13

Heparin syringe size

__________________________________
(e.g., 10ml)

Heparin volume in syringe

__________________________________
(total volume of liquid product in the syringe in
ml)

Provide catalog (REF) number:

__________________________________

Heparin flush lot #

__________________________________
(Lot # if known)

Does this lot # correspond to what was administered
to this patient, available on the patient unit
within the 48 hours prior to symptom onset,
available in the facility within the 48 hours prior
to symptom onset, or currently in stock at the time
of public health investigation?

Administered to patient
Available on the patient unit within the 48 hours
prior to symptom onset
Available in the facility within 48 hours prior to
symptom onset
Currently in stock at the time of public health
investigation
(Please check the most specific option (i.e., if
used on this specific patient and used on the
unit, check "used on this patient."))

Heparin flush name 2

__________________________________
(name and of the heparin product to include
manufacturer, sterile field or not, etc.)

When was this product used?

< 48 hours prior to (+) culture
48 hours - 7 days prior to (+) culture

Was this product administered inside the facility or
outside the facility?

Inside facility
Outside facility
Both

Was this product administered by hand or using a
pump?

By hand
Pump
Other (specify)

Specify how heparin was administered.

__________________________________

Heparin concentration 2

__________________________________
(typically given in units/ml such as 10u/ml or
100u/ml)

Heparin syringe size 2

__________________________________
(e.g., 10ml)

Heparin volume in syringe 2

__________________________________
(total volume of liquid product in the syringe in
ml)

Provide catalog (REF) number:

__________________________________

Heparin flush lot # 2

__________________________________
(Lot # if known)

Public reporting burden of this collection of information is estimated to average 2 hours per response, including the time for reviewing
instructions, searching existing data sources, gathering and maintaining the data needed, andcompleting and reviewing the collection
of information. An agency may not conduct or sponsor, and a person is notrequired 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/ATSDR Reports Clearance Officer, 1600 Clifton Road NE,
MS D-74, Atlanta, Georgia 30333; ATTN: PRA 0920-XXXX
04/24/2018 9:48am

www.projectredcap.org

Confidential

Form Approved
OMB Control No. 0920-XXXX
Exp. date: XX/XX/XXXX

Page 12 of 13

Does this lot # correspond to what was administered
to this patient, available on the patient unit
within the 48 hours prior to symptom onset,
available in the facility within the 48 hours prior
to symptom onset, or currently in stock at the time
of public health investigation?

Administered to patient
Available on the patient unit within the 48 hours
prior to symptom onset
Available in the facility within 48 hours prior to
symptom onset
Currently in stock at the time of public health
investigation
(Please check the most specific option (i.e., if
used on this specific patient and used on the
unit, check "used on this patient."))

Heparin flush name 3

__________________________________
(name and of the heparin product to include
manufacturer, sterile field or not, etc.)

When was this product used?

< 48 hours prior to (+) culture
48 hours - 7 days prior to (+) culture

Was this product administered inside the facility or
outside the facility?

Inside facility
Outside facility
Both

Was this product administered by hand or using a
pump?

By hand
Pump
Other (specify)

Specify how heparin was administered.

__________________________________

Heparin concentration 3

__________________________________
(typically given in units/ml such as 10u/ml or
100u/ml)

Heparin syringe size 3

__________________________________
(e.g., 10ml)

Heparin volume in syringe 3

__________________________________
(total volume of liquid product in the syringe in
ml)

Provide catalog (REF) number:

__________________________________

Heparin flush lot # 3

__________________________________
(Lot # if known)

Does this lot # correspond to what was administered
to this patient, available on the patient unit
within the 48 hours prior to symptom onset,
available in the facility within the 48 hours prior
to symptom onset, or currently in stock at the time
of public health investigation?

Administered to patient
Available on the patient unit within the 48 hours
prior to symptom onset
Available in the facility within 48 hours prior to
symptom onset
Currently in stock at the time of public health
investigation
(Please check the most specific option (i.e., if
used on this specific patient and used on the
unit, check "used on this patient."))

Regardless of the answers to the above questions, did
this patient receive any compounded medications
prepared with a BD heparin or saline flush?

Yes
No

Public reporting burden of this collection of information is estimated to average 2 hours per response, including the time for reviewing
instructions, searching existing data sources, gathering and maintaining the data needed, andcompleting and reviewing the collection
of information. An agency may not conduct or sponsor, and a person is notrequired 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/ATSDR Reports Clearance Officer, 1600 Clifton Road NE,
MS D-74, Atlanta, Georgia 30333; ATTN: PRA 0920-XXXX

04/24/2018 9:48am

www.projectredcap.org

Confidential Form Approved

OMB Control No. 0920-XXXX
Exp. date: XX/XX/XXXX

Page 13 of 13

If yes to the above, specify what the patient
received.

__________________________________
(Include as much information as possible, e.g. lot
number, catalog number, volume, diameter, etc.)

If yes to the above, what was the date(s) of
administration?

__________________________________

Additional exposure questions
Other line products used

__________________________________
(Within the 7 days prior to symptom onset, eg.
Chlorhexadine, antibiotics, alcohol scrub, line
caps, dressing change kit; please be as specific
as possible to include manufacturers,
description, lot #, etc.)

Location where line products used

__________________________________
(e.g., acute care facility type, outpatient
location, etc.)

List the steps, in order, for the normal line flush
and heplock procedures.

__________________________________________

Other common non-line product exposures and locations
__________________________________________
(Free text notes on whatever other common exposure
might exist among cases - please note which other
cases have the exposure listed. Please include
exposures from home health care, outpatient
healthcare visits, dialysis, etc. and provide as
much detail as possible (but do not include
actual names of facilities/agencies).)
Any additional concerning exposures that are outside
the 7 day window?

__________________________________________

Public reporting burden of this collection of information is estimated to average 2 hours 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/ATSDR Reports Clearance Officer, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia
30333; ATTN: PRA 0920-XXXX

04/24/2018 9:48am

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