Patient Information

Prevalence Survey of Healthcare Associated Infections (HAIs) and Antimicrobial Use in U.S. Acute Care Hospitals

Attachment_D_PIF

OMB: 0920-0852

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Form Approved

OMB No. 0920-0852

Exp. Date xx/xx/xxxx


HAI & ANTIMICROBIAL USE PREVALENCE SURVEY

PATIENT INFORMATION FORM

CDC ID: ____ - ______________ Survey date: ___ /___ /_______ Data collector initials: ____________

If data collected on survey date, enter data collection time: ___ : ____ am pm OR Data collection done retrospectively

I. Identifiers (NOT transmitted to CDC)

Patient name: __________________________________

Date of birth (mm/dd/yyyy): ______ / ______ / __________

Hospital name: _________________________________

Hospital unit name: ____________________________

Room number: _________________________________

Medical record no.: ____________________________


II. Demographic information


Admission date (mm/dd/yyyy): _____ / _____ / _________

CDC location code: __________________________

Age: _____ yrs mos dys Unknown

Primary Payer:

Medicare

Medicaid

Private insurance

Self-pay

No charge

Other

Unknown


Ethnicity: (check one)

Hispanic or Latino

Not Hispanic or Latino

Not Documented

Race: (check all that apply)

American Indian or Alaska Native Other

Asian Not Documented

Black or African American

Native Hawaiian/other Pacific Islander

White

Sex at birth:

Male Female Unknown


III. Weight and height

Weight:______lbs. ______ oz.

OR _____kg Unknown

Height:______ft. _____ in.

OR _____cm Unknown

BMI: (record only if height or weight unavailable)

_____________ Unknown NA


IV. Devices and pressure injuries/ulcers present on the survey date

Urinary catheter: Yes No Unknown

Ventilator: Yes No Unknown

Central line: Yes No Unknown If “Yes,” indicate how many lines: 1 line >1 line Unknown

Pressure injury or ulcer: Yes No Unknown

If “Yes” did any pressure injuries or ulcers develop after admission?

Yes No Unknown    

Indicate the highest stage of the pressure injuries Stage 1  Stage 2 Stage 3 Stage 4 

or ulcers on the survey date:    Unstageable   Unknown


V. COVID-19 status

SARS-CoV-2 viral test(s) performed during the 14 days before hospital admission through the survey date (check all that apply):

Positive test; Enter positive test collection date closest to survey date (mm/dd/yyyy): _____/_____/________

Negative test; Enter negative test collection date closest to survey date (mm/dd/yyyy): _____/_____/________

No test performed

Unknown


VI. Antimicrobials administered or scheduled to be administered:

On the survey date: Yes No Unknown

On the day before the survey date: Yes No Unknown

VI. Follow-up information

Enter date of follow-up data collection: ____ / ____ / _________ (must be at least 6 months after the survey date)

Hospital discharge date: ____ / ____ / _________ OR check one: Unknown Still in hospital

Patient outcome at time of hospital discharge: Survived Died Unknown Still in hospital

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Public reporting burden of this collection of information is estimated to average 17 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 Information Collection Request Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30329; ATTN: PRA (0920-0852).





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FORM IS COMPLETE


HAIPS 2021_ 20210623 Page 1 of 2

File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
AuthorShelley Magill
File Modified0000-00-00
File Created2023-08-27

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