Form 0920-19AYV AR Lab Network Alert Report Form for C auris

Public Health Laboratory Testing for Emerging Antibiotic Resistance and Fungal Threats

Attachment 3g Form 7 AR Lab Network Alert Report Form for C auris final

AR Lab network Alert Report Form for C auris

OMB: 0920-1310

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Form Approved

OMB Control No.: 0920-XXXX

Expiration date: XX/XX/XXXX


AR Lab Network Alert Form for Candida auris

Regional lab or non-regional lab

State or jurisdiction of the data submitter

If non-regional lab, was isolate forwarded to regional lab?

If isolate was forwarded to regional lab, which regional lab?

ARLN isolate ID

ARLN specimen ID

Submitter specimen ID

Alert type

If alert is for C. auris, is it for C. auris identification?

If alert is for C. auris, is it for C. auris echinocandin resistance?

Facility – name

Facility – ID

Facility – state

Specimen collection date

Specimen type

Patient ID

Patient age

Patient age unit

Clinical sample or isolate

Completion status



Public reporting burden of this collection of information is estimated to average 6 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/ATSDR Reports Clearance Officer, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA 0920-XXXX


File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
AuthorGilbert, Sarah (CDC/DDID/NCEZID/DHQP) (CTR)
File Modified0000-00-00
File Created2021-01-14

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