Patient Information

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

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).

FORM IS COMPLETE

HAIPS 2021_ 20210623 Page 1 of 2