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 Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Gilbert, Sarah (CDC/DDID/NCEZID/DHQP) (CTR) |
| File Modified | 0000-00-00 |
| File Created | 2021-01-14 |