August 2022 Change Request Justification

Non-Substantive Change Request to OMB Control Number 0920-0852

Contact

Nora Chea, MD, MSc

National Center for Emerging and Zoonotic Infectious Diseases

Centers for Disease Control and Prevention

1600 Clifton Road, NE

Atlanta, Georgia 30333

Phone: (404)-639-0025

Email: [email protected]

Submission Date: 08/02/2022

CDC requests approval for non-substantive changes to OMB Control No. 0920-0852: Prevalence Survey of Healthcare Associated Infections (HAIs) and Antimicrobial Use in U.S. Acute Care Hospitals. All proposed changes are consistent with previously approved goals and methods.

The types of changes are summarized as follows:

1. Minor changes to facilitate form use and administration

   1. Changes to clarify the wording of selected questions, examples, or response options

   2. Update the time frame of the survey from “2018 and 2019” to “2022 and 2023”

   3. Remove “must be at least 6 months after the survey date” to permit greater flexibility in scheduling follow-up data collection

2. COVID-19 reporting

   1. Modify the currently approved question about SARS-CoV-2 viral test(s) to ascertain whether the infection was likely acquired prior to, or during, the hospital admission

   2. Add a new question about COVID-19 vaccination

   3. Add COVID-19 or SARS-CoV-2 as a response option in selected questions

3. Location

   1. Supplement current data elements about patient residential addresses to permit geocoding and enhance understanding of epidemiologic and contextual factors

4. Add one form (correction of an administrative error)

   1. This change request includes the addition of one form (Attachment_C1_EIP HFA) which was approved and used in the 2015 cycle of survey administration (View Information Collection Request (ICR) Package (reginfo.gov)). Due to an administrative oversight the form was not included in the most recent Extension ICR and we request to incorporate it at this time. This form is used by local site EIP staff and does not pose burden on the public.

Impact of Proposed Changes on Burden

The proposed changes do not alter the estimated burden for this information collection. Minor changes are proposed for two forms that are listed in the burden table. These are the “HAI & ANTIMICROBIAL USE PREVALENCE SURVEY HEALTHCARE FACILITY ASSESSMENT” form and the “HAI & ANTIMICROBIAL USE PREVALENCE SURVEY PATIENT INFORMATION FORM.” A description of changes to these two forms and justifications for the changes appear below. There is no change to the estimated burden per response for either form, as the minor additions are offset by clarifications that improve ease of use.

In this Change Request, CDC also proposes changes to other forms that are not listed in the ICR burden table (Supporting Statement section A.12). These forms are completed by EIP site personnel and the time associated with their completion is assessed as an Annualized Cost to the Government (Supporting Statement section A.14). Please see the supplemental section of this Change Request for detailed changes and justifications to those forms.

Justifications for changes to forms that pose burden to the public:

HAI & ANTIMICROBIAL USE PREVALENCE SURVEY PATIENT INFORMATION FORM (Attachment_D_PIF)

1. We propose to add patient address including street address, city, state, ZIP code, and address type fields in Section I (Identifiers). Information reported in these fields WILL NOT be transmitted to CDC. Emerging Infection Program (EIP) sites will use the address and address type information to accurately geocode the patients’ addresses and link patients’ data with census tract information. Geocoding patients included in this survey will enable an evaluation of potential associations between social determinants of health and HAI or antimicrobial use.

2. We propose to separate the question about COVID-19 status in section V to ask about 1) SARS-CoV-2 viral test(s) performed during the 14 days before hospital admission or the first 2 days of hospital admission and 2) SARS-CoV-2 viral test(s) performed on or after hospital day 3 (day 1= admission date) through the survey date. We also propose to add a question about COVID-19 vaccination. This information will allow us to identify patients with a potential healthcare-associated SARS-CoV-2 infection and the percentage of patients who have received COVID-19 vaccines.

3. We propose to remove “must be at least 6 months after the survey date” from Section VI (Follow-up information). This will allow data collectors to conduct a follow-up data collection less than 6 months after the survey date.

HAI & ANTIMICROBIAL USE PREVALENCE SURVEY HEALTHCARE FACILITY ASSESSMENT (Attachment_C_HFA)

1. We propose to change answer choices for question 3 from “2018 and 2019” to “2022 and 2023” to allow data collectors to check the correct year instead of writing it as a free text in “Other” field.

2. We propose to add “or health system” in question 5. Sometimes, an infection control team or program serves the whole health system, not just the participating facility. This change will make the question more applicable for those settings.

3. We propose to add “staff” behind three answer choices including “quality department”, “pharmacy department”, and “environmental services” in question 10. This addition makes the answer choices more consistent with other answer choices in this question since the other answer choices refer to people such as administrators, supervisors, etc.

4. We also propose to add “GI panel” as an example for “nucleic acid amplification test (NAAT) in question 17. This addition reflects the updated testing options for Clostridioides difficile.

Burden:

Because the changes to the forms are minimal, the estimates of annualized burden hours for this change request will stay the same.

The burden estimate for the forms included in OMB Control No. 0920-0852 is 1,860 hours.

Type of Respondents	Form Name	No. of Respondents	No. of Responses per Respondent	Avg. Burden per Response (Hours)	Total Burden (Hours)
Hospital Staff (i.e., Infection Preventionist)	Healthcare Facility Assessment (HFA)	100	1	45/60	75
	Patient Information Form (PIF)	100	63	17/60	1,785
Total (Hours)					1,860

Description of Changes to forms that pose burden to the public:

The changes to the form are as follows:

HAI & ANTIMICROBIAL USE PREVALENCE SURVEY PATIENT INFORMATION FORM (Attachment_D_PIF)

1. Patient address including street address, city, state, ZIP code, and address type fields were added in Section I (Identifiers).

Patient address: ________________________________ City: __________State: __________ZIP: __________

Address type: (check one)

Residential Other

Post office box Insufficient

Long-term care facility Missing

Corrections

Military

Homeless

2. Question about COVID-19 status in section V was separated to ask about 1) SARS-CoV-2 viral test(s) performed during the 14 days before hospital admission or the first 2 days of hospital admission and 2) SARS-CoV-2 viral test(s) performed on or after hospital day 3 (day 1= admission date) through the survey date. Question about COVID-19 vaccination was added.

V. COVID-19 status

SARS-CoV-2 viral test(s) performed during the 14 days before hospital admission or the first 2 days of hospital admission (check all that apply):

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

Unknown

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

Unknown

No test performed

Unknown

SARS-CoV-2 viral test(s) performed on or after hospital day 3 (day 1= admission date) through the survey date (check all that apply):

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

Unknown

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

Unknown

No test performed

Unknown

Has the patient received any COVID-19 vaccine prior to survey date?

Yes

No

Unknown

If yes, enter the number of COVID-19 vaccine doses the patient has received: _________ Unknown

3. The phrase “must be at least 6 months after the survey date” was removed from Section VI (Follow-up information).

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

HAI & ANTIMICROBIAL USE PREVALENCE SURVEY HEALTHCARE FACILITY ASSESSMENT (Attachment_C_HFA)

1. Answer choices for question 3 were changed from “2018 and 2019” to “2022 and 2023”

3. Complete the following table for your hospital, using the most current data available to you:

Hospital characteristic	Number	What year are data from?
No. of acute care licensed beds Do not include nursing home or skilled nursing facility beds.	________ or ☐ Unknown	☐2022 ☐2023 ☐Other: ______
No. of acute care staffed beds Do not include nursing home or skilled nursing facility beds.	___________ or ☐ Unknown	☐2022 ☐2023 ☐Other: ______
No. of full time equivalent (FTE) infection preventionists Enter the number of FTEs to the nearest hundredth of an FTE. For example, if you have three staff members who each spend 35% of their time on infection prevention, you would enter 1.05 FTE. If you do not have any staff who serve part- or full-time as an infection preventionist, check “None.” If you do not know if your hospital has any part- or full-time infection preventionists, check “Unknown.”	(enter number as a decimal) _________ or ☐ None ☐ Unknown	☐2022 ☐2023 ☐Other: ______
No. of FTE physician hospital epidemiologists Enter the no. of FTEs to the nearest hundredth of an FTE. For example, if you have two physician who spends 45% of their time as hospital epidemiologists, you would enter 0.9 FTE. If you do not have any physicians who serve part- or full-time as a hospital epidemiologists, check “None.” If you do not know if your hospital has any part- or full-time hospital epidemiologists, check “Unknown.”	(enter number as a decimal) _________ or ☐ None ☐ Unknown	☐2022 ☐2023 ☐Other: ______
Number of FTE interns/residents Enter the number of FTE interns or residents that work in your hospital to the nearest hundredth of an FTE (e.g., 50.25 FTE). If your hospital does not have any interns or residents, check “None” and skip to Question #4. If you do not know if your hospital has interns or residents, check “Unknown.”	(enter number as a decimal) ________ or ☐ None ☐ Unknown	☐2022 ☐2023 ☐Other: ______
If your hospital has interns or residents: Provide the official intern/resident to bed ratio (IRB) If you do not know your hospital’s official IRB, check “Unknown”.	☐ <0.25 ☐ ≥0.25 ☐ Unknown	☐2022 ☐2023 ☐Other: ______

2. “or health system” was added in question 5.

5. Does your facility or health system have an infection control team or program with at least one staff member responsible for developing and implementing infection control policies and practices and related activities?

☐ Yes

☐ No (if “No”, skip to question #9)

3. “staff” was added behind three answer choices including “quality department”, “pharmacy department”, and “environmental services” in question 10.

10. If there is a committee in your hospital that reviews infection control-related activities, indicate the members represented on the committee (check all that apply):

☐ Facility executive leaders (e.g., CEO, COO) or board members

☐ Nursing leaders or administrators

☐ Medical/physician leaders or administrators

☐ Quality department staff

☐ Pharmacy department staff

☐ Environmental services staff

☐ Nursing unit managers or supervisors

☐ Physician staff

☐ Nursing staff

☐ Other (specify): ____________________________________________________________

4. “GI panel” was added as an example for “nucleic acid amplification test (NAAT) in question 17.

For EIP Team use only: Hospital ID: __________________________________________

17. What is the primary testing method for Clostridioides difficile (C. difficile) used most often by your hospital’s laboratory or the outside laboratory where your hospital’s testing is performed (Choose one)?

☐ Enzyme immunoassay (EIA) for toxin

☐ Cell cytotoxicity neutralization assay

☐ Nucleic acid amplification test (NAAT) (e.g., PCR, LAMP, GI panel)

☐ NAAT plus EIA, if NAAT positive (2-step algorithm)

☐ Glutamate dehydrogenase (GDH) antigen plus EIA for toxin (2-step algorithm)

☐ GDH plus NAAT (2-step algorithm)

☐ GDH plus EIA for toxin, followed by NAAT for discrepant results

☐ Toxigenic culture (C. difficile culture followed by detection of toxins)

☐ Other (specify): ______________________________________________________________________

Form

Current question

Requested change

HAI & ANTIMICROBIAL USE PREVALENCE SURVEY PATIENT INFORMATION FORM

I. Identifiers (NOT transmitted to CDC)
Patient name: _______________________	Date of birth (mm/dd/yyyy): ______ / ______ / __________
Hospital name: _______________________	Hospital unit name: ___________________
Room number: ______________________	Medical record no.: ___________________

I. Identifiers (NOT transmitted to CDC)
Patient name: _______________________________	Date of birth (mm/dd/yyyy): ______ / ______ / __________
Patient address: _______________	City:
State: ZIP:
Address type: (check one) Residential Other Post office box Insufficient Long-term care facility Missing Corrections Military Homeless
Hospital name: ________________________________	Hospital unit name: ____________________________
Room number: ________________________________	Medical record no.: ____________________________

HAI & ANTIMICROBIAL USE PREVALENCE SURVEY PATIENT INFORMATION FORM

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

V. COVID-19 status

SARS-CoV-2 viral test(s) performed during the 14 days before hospital admission or the first 2 days of hospital admission (check all that apply):

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

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

No test performed

Unknown

SARS-CoV-2 viral test(s) performed on or after hospital day 3 (day 1= admission date) through the survey date (check all that apply):

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

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

No test performed

Unknown

Has the patient received any COVID-19 vaccine prior to survey date?

Yes

No

Unknown

If yes, enter the number of COVID-19 vaccine doses the patient has received:

_________ Unknown

HAI & ANTIMICROBIAL USE PREVALENCE SURVEY PATIENT INFORMATION FORM

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

Enter date of follow-up data collection: ____ / ____ / _________

HAI & ANTIMICROBIAL USE PREVALENCE SURVEY HEALTHCARE FACILITY ASSESSMENT

	Number	What year are data from?
No. of acute care licensed beds Do not include nursing home or skilled nursing facility beds.	________ or ☐ Unknown	☐2018 ☐2019 ☐Other: ______
No. of acute care staffed beds Do not include nursing home or skilled nursing facility beds.	___________ or ☐ Unknown	☐2018 ☐2019 ☐Other: ______
No. of full time equivalent (FTE) infection preventionists Enter the number of FTEs to the nearest hundreth of an FTE. For example, if you have three staff members who each spend 35% of their time on infection prevention, you would enter 1.05 FTE. If you do not have any staff who serve part- or full-time as an infection preventionist, check “None.” If you do not know if your hospital has any part- or full-time infection preventionists, check “Unknown.”	(enter number as a decimal) _________ or ☐ None ☐ Unknown	☐2018 ☐2019 ☐Other: ______
No. of FTE physician hospital epidemiologists Enter the no. of FTEs to the nearest hundredth of an FTE. For example, if you have two physician who spends 45% of their time as hospital epidemiologists, you would enter 0.9 FTE. If you do not have any physicians who serve part- or full-time as a hospital epidemiologists, check “None.” If you do not know if your hospital has any part- or full-time hospital epidemiologists, check “Unknown.”	(enter number as a decimal) _________ or ☐ None ☐ Unknown	☐2018 ☐2019 ☐Other: ______
Number of FTE interns/residents Enter the number of FTE interns or residents that work in your hospital to the nearest hundredth of an FTE (e.g., 50.25 FTE). If your hospital does not have any interns or residents, check “None” and skip to Question #4. If you do not know if your hospital has interns or residents, check “Unknown.”	(enter number as a decimal) ________ or ☐ None ☐ Unknown	☐2018 ☐2019 ☐Other: ______
If your hospital has interns or residents: Provide the official intern/resident to bed ratio (IRB) If you do not know your hospital’s official IRB, check “Unknown”.	☐ <0.25 ☐ ≥0.25 ☐ Unknown	☐2018 ☐2019 ☐Other: ______

Hospital characteristic	Number	What year are data from?
No. of acute care licensed beds Do not include nursing home or skilled nursing facility beds.	________ or ☐ Unknown	☐2022 ☐2023 ☐Other: ______
No. of acute care staffed beds Do not include nursing home or skilled nursing facility beds.	___________ or ☐ Unknown	☐2022 ☐2023 ☐Other: ______
No. of full time equivalent (FTE) infection preventionists Enter the number of FTEs to the nearest hundredth of an FTE. For example, if you have three staff members who each spend 35% of their time on infection prevention, you would enter 1.05 FTE. If you do not have any staff who serve part- or full-time as an infection preventionist, check “None.” If you do not know if your hospital has any part- or full-time infection preventionists, check “Unknown.”	(enter number as a decimal) _________ or ☐ None ☐ Unknown	☐2022 ☐2023 ☐Other: ______
No. of FTE physician hospital epidemiologists Enter the no. of FTEs to the nearest hundredth of an FTE. For example, if you have two physician who spends 45% of their time as hospital epidemiologists, you would enter 0.9 FTE. If you do not have any physicians who serve part- or full-time as a hospital epidemiologists, check “None.” If you do not know if your hospital has any part- or full-time hospital epidemiologists, check “Unknown.”	(enter number as a decimal) _________ or ☐ None ☐ Unknown	☐2022 ☐2023 ☐Other: ______
Number of FTE interns/residents Enter the number of FTE interns or residents that work in your hospital to the nearest hundredth of an FTE (e.g., 50.25 FTE). If your hospital does not have any interns or residents, check “None” and skip to Question #4. If you do not know if your hospital has interns or residents, check “Unknown.”	(enter number as a decimal) ________ or ☐ None ☐ Unknown	☐2022 ☐2023 ☐Other: ______
If your hospital has interns or residents: Provide the official intern/resident to bed ratio (IRB) If you do not know your hospital’s official IRB, check “Unknown”.	☐ <0.25 ☐ ≥0.25 ☐ Unknown	☐2022 ☐2023 ☐Other: ______

HAI & ANTIMICROBIAL USE PREVALENCE SURVEY HEALTHCARE FACILITY ASSESSMENT

5. Does your facility have an infection control team or program with at least one staff member responsible for developing and implementing infection control policies and practices and related activities?

☐Yes

☐No (if “No”, skip to question #9)

5. Does your facility or health system have an infection control team or program with at least one staff member responsible for developing and implementing infection control policies and practices and related activities?

☐ Yes

☐ No (if “No”, skip to question #9)

HAI & ANTIMICROBIAL USE PREVALENCE SURVEY HEALTHCARE FACILITY ASSESSMENT

10. If there is a committee in your hospital that reviews infection control-related activities, indicate the members represented on the committee (check all that apply):

☐ Facility executive leaders (e.g., CEO, COO) or board members

☐ Nursing leaders or administrators

☐ Medical/physician leaders or administrators

☐ Quality department

☐ Pharmacy department

☐ Environmental services

☐ Nursing unit managers or supervisors

☐ Physician staff

☐ Nursing staff

☐ Other (specify): ____________________________________________________________

10. If there is a committee in your hospital that reviews infection control-related activities, indicate the members represented on the committee (check all that apply):

☐ Facility executive leaders (e.g., CEO, COO) or board members

☐ Nursing leaders or administrators

☐ Medical/physician leaders or administrators

☐ Quality department staff

☐ Pharmacy department staff

☐ Environmental services staff

☐ Nursing unit managers or supervisors

☐ Physician staff

☐ Nursing staff

☐ Other (specify): ____________________________________________________________

HAI & ANTIMICROBIAL USE PREVALENCE SURVEY HEALTHCARE FACILITY ASSESSMENT

17. 

    
    

    For EIP Team use only: Hospital ID: __________________________________________

    
    

    What is the primary testing method for Clostridioides difficile (C. difficile) used most often by your hospital’s laboratory or the outside laboratory where your hospital’s testing is performed (Choose one)?

☐ Enzyme immunoassay (EIA) for toxin

☐ Cell cytotoxicity neutralization assay

☐ Nucleic acid amplification test (NAAT) (e.g., PCR, LAMP

☐ NAAT plus EIA, if NAAT positive (2-step algorithm)

☐ Glutamate dehydrogenase (GDH) antigen plus EIA for toxin (2-step algorithm)

☐ GDH plus NAAT (2-step algorithm)

☐ GDH plus EIA for toxin, followed by NAAT for discrepant results

☐ Toxigenic culture (C. difficile culture followed by detection of toxins)

☐ Other (specify): ______________________________________________________________________

For EIP Team use only: Hospital ID: __________________________________________

17. What is the primary testing method for Clostridioides difficile (C. difficile) used most often by your hospital’s laboratory or the outside laboratory where your hospital’s testing is performed (Choose one)?

☐ Enzyme immunoassay (EIA) for toxin

☐ Cell cytotoxicity neutralization assay

☐ Nucleic acid amplification test (NAAT) (e.g., PCR, LAMP, GI panel)

☐ NAAT plus EIA, if NAAT positive (2-step algorithm)

☐ Glutamate dehydrogenase (GDH) antigen plus EIA for toxin (2-step algorithm)

☐ GDH plus NAAT (2-step algorithm)

☐ GDH plus EIA for toxin, followed by NAAT for discrepant results

☐ Toxigenic culture (C. difficile culture followed by detection of toxins)

☐ Other (specify): ______________________________________________________________________

Supplemental section

Justifications for changes to forms that do not pose burden to the public:

HAI & ANTIMICROBIAL USE PREVALENCE SURVEY ANTIMICROBIAL QUALITY ASSESSMENT (AQUA) FORM 2: GENERAL PATIENT ASSESSMENT (Attachment_H_AQUA General Patient Assessment Form)

1. We propose to add “COVID-19 specific treatment” to question 2 asking what the patient received in the 30 days prior to admission to the survey hospital. This addition will allow us to better describe patients who meet inclusion criteria for antimicrobial quality assessment.

HAI & ANTIMICROBIAL USE PREVALENCE SURVEY: ANTIMICROBIAL QUALITY ASSESSMENT (AQUA) FORM; 3a: VANCOMYCIN (Attachment_I_a_AQUA Vancomycin Form)

1. We propose to add “SARS-CoV-2” to the list of pathogens that were tested for in question 6 of the form. This addition will allow data collectors to check a box instead of writing SARS-CoV-2 as a free text under “Other” field.

HAI & ANTIMICROBIAL USE PREVALENCE SURVEY: ANTIMICROBIAL QUALITY ASSESSMENT (AQUA) FORM; 3b: FLUOROQUINOLONE (Attachment_I_b_AQUA Fluoroquinolone Form)

1. We propose to add “SARS-CoV-2” to the list of pathogens that were tested for in question 5 of the form. This addition will allow data collectors to check a box instead of writing SARS-CoV-2 as a free text under “Other” field.

HAI & ANTIMICROBIAL USE PREVALENCE SURVEY: ANTIMICROBIAL QUALITY ASSESSMENT (AQUA) FORM; 3c: CAP (Attachment_I_c_AQUA CAP_Form)

1. We propose to add “Unknown” as an answer choice in question 1 of the form to allow data collectors to report in a situation when ICD-10 codes on admission are not known for the patient.

2. We also propose to add “SARS-CoV-2” to the list of pathogens that were tested for in question 13 of the form. This addition will allow data collectors to check a box instead of writing SARS-CoV-2 as a free text under “Other” field.

HAI & ANTIMICROBIAL USE PREVALENCE SURVEY: ANTIMICROBIAL QUALITY ASSESSMENT (AQUA) FORM; 3d: UTI (Attachment_I_d_AQUA UTI_Form)

1. We propose to add “Unknown” as an answer choice in question 1 of the form to allow data collectors to report in a situation when ICD-10 codes on admission are not known for the patient.

2. We also propose to add “SARS-CoV-2” to the list of pathogens that were tested for in question 12 of the form. This addition will allow data collectors to check a box instead of writing SARS-CoV-2 as a free text under “Other” field.

HAI & ANTIMICROBIAL USE PREVALENCE SURVEY: HAI FORM (Attachment_E_HAI Form)

1. We propose to add “ECLS” and “Hemodialysis catheter” under BSI section.

2. We propose to separate USI from UTI and make it a standalone HAI type.

3. We also propose to delete Candida albicans and Candida parapsolosis and update the list of antimicrobial drugs tested for Acinetobacter, Candida albicans, Escherichia coli, Enterobacter cloacae, Klebsiella pneumoniae, Enterococcus faecalis, and Enterococcus faecium to be consistent with NHSN case report forms.

Description of Changes to forms that do not pose burden to the public:

HAI & ANTIMICROBIAL USE PREVALENCE SURVEY ANTIMICROBIAL QUALITY ASSESSMENT (AQUA) FORM 2: GENERAL PATIENT ASSESSMENT (Attachment_H_AQUA General Patient Assessment Form)

1. “COVID-19 specific treatment” was added as an answer choice in question 2

2. In the 30 days prior to admission to the survey hospital, did the patient receive (check all that apply):

IV antimicrobials Cancer chemotherapy Wound care Chronic hemodialysis Surgery

None Unknown COVID-19 specific treatment

HAI & ANTIMICROBIAL USE PREVALENCE SURVEY: ANTIMICROBIAL QUALITY ASSESSMENT (AQUA) FORM; 3a: VANCOMYCIN (Attachment_I_a_AQUA Vancomycin Form)

1. “SARS-CoV-2” was added to the list of pathogens that were tested for in question 6 of the form.

6. Complete the table for non-culture microbiology tests (positive and negative) collected from 5 days before vancomycin IV first date through the vancomycin IV last date:

No non-culture tests done: Non-culture test data unknown:

No.	Collect date (mm/dd/yy)	Specimen	Test	What pathogen(s) were tested for?	Result
1	____ / ___ / ___	Blood Lower resp Upper resp Urine Stool Other ______	PCR DFA Antigen test Other_____	Legionella Cdiff RSV Pneumococcus Adeno Influenza hMPV Paraflu Other ________ SARS-CoV-2	Negative Unknown Positive (insert code): Path1_______Path2_______ Path3_______
2	____ / ___ / ___	Blood Lower resp Upper resp Urine Stool Other ______	PCR DFA Antigen test Other_____	Legionella Cdiff RSV Pneumococcus Adeno Influenza hMPV Paraflu Other ________ SARS-CoV-2	Negative Unknown Positive (insert code): Path1_______Path2_______ Path3_______
3	____ / ___ / ___	Blood Lower resp Upper resp Urine Stool Other ______	PCR DFA Antigen test Other_____	Legionella Cdiff RSV Pneumococcus Adeno Influenza hMPV Paraflu Other ________ SARS-CoV-2	Negative Unknown Positive (insert code): Path1_______Path2_______ Path3_______
4	____ / ___ / ___	Blood Lower resp Upper resp Urine Stool Other ______	PCR DFA Antigen test Other_____	Legionella Cdiff RSV Pneumococcus Adeno Influenza hMPV Paraflu Other ________ SARS-CoV-2	Negative Unknown Positive (insert code): Path1_______Path2_______ Path3_______
5	____ / ___ / ___	Blood Lower resp Upper resp Urine Stool Other ______	PCR DFA Antigen test Other_____	Legionella Cdiff RSV Pneumococcus Adeno Influenza hMPV Paraflu Other ________ SARS-CoV-2	Negative Unknown Positive (insert code): Path1_______Path2_______ Path3_______

More tests than fit in the table:

HAI & ANTIMICROBIAL USE PREVALENCE SURVEY: ANTIMICROBIAL QUALITY ASSESSMENT (AQUA) FORM; 3b: FLUOROQUINOLONE (Attachment_I_b_AQUA Fluoroquinolone Form)

1. “SARS-CoV-2” was added to the list of pathogens that were tested for in question 5 of the form.

5. Complete the table for non-culture microbiology tests (positive and negative) collected from 5 days before fluoroquinolone first date through the fluoroquinolone last date:

No non-culture tests done: Non-culture test data unknown:

No.	Collect date (mm/dd/yy)	Specimen	Test	What pathogen(s) were tested for?	Result
1	____ / ___ / ___	Blood Lower resp Upper resp Urine Stool Other ______	PCR DFA Antigen test Other_____	Legionella Cdiff RSV Pneumococcus Adeno Influenza hMPV Paraflu Other ________ SARS-CoV-2	Negative Unknown Positive (insert code): Path1_______Path2_______ Path3_______
2	____ / ___ / ___	Blood Lower resp Upper resp Urine Stool Other ______	PCR DFA Antigen test Other_____	Legionella Cdiff RSV Pneumococcus Adeno Influenza hMPV Paraflu Other ________ SARS-CoV-2	Negative Unknown Positive (insert code): Path1_______Path2_______ Path3_______
3	____ / ___ / ___	Blood Lower resp Upper resp Urine Stool Other ______	PCR DFA Antigen test Other_____	Legionella Cdiff RSV Pneumococcus Adeno Influenza hMPV Paraflu Other ________ SARS-CoV-2	Negative Unknown Positive (insert code): Path1_______Path2_______ Path3_______
4	____ / ___ / ___	Blood Lower resp Upper resp Urine Stool Other ______	PCR DFA Antigen test Other_____	Legionella Cdiff RSV Pneumococcus Adeno Influenza hMPV Paraflu Other ________ SARS-CoV-2	Negative Unknown Positive (insert code): Path1_______Path2_______ Path3_______
5	____ / ___ / ___	Blood Lower resp Upper resp Urine Stool Other ______	PCR DFA Antigen test Other_____	Legionella Cdiff RSV Pneumococcus Adeno Influenza hMPV Paraflu Other ________ SARS-CoV-2	Negative Unknown Positive (insert code): Path1_______Path2_______ Path3_______

More tests than fit in the table:

HAI & ANTIMICROBIAL USE PREVALENCE SURVEY: ANTIMICROBIAL QUALITY ASSESSMENT (AQUA) FORM; 3c: CAP (Attachment_I_c_AQUA CAP_Form)

1. “Unknown” was added as an answer choice in question 1 of the form.

1. Check any of the following ICD-10 codes that were present on admission for this patient: None Unknown

J09.X1 J09.X2 J09.X3 J10.00 J10.01 J10.08 J10.1 J10.2 J10.81 J10.82 J10.83 J10.89 J11.00 J11.08 J11.1 J11.2 J11.81 J11.82 J11.83 J11.89 J12.0 J12.1 J12.2 J12.3 J12.81 J12.89 J12.9 J13 J14 J15.0 J15.1 J15.3 J15.4 J15.20 J15.211 J15.212 J15.29 J15.5 J15.6 J15.7 J15.8 J15.9 J16.0 J16.8 J18.0 J18.1 J18.9 A48.1 Other (specify):_____

2. “SARS-CoV-2” was added to the list of pathogens that were tested for in question 13 of the form.

13. Complete the table for non-culture microbiology tests (positive and negative) collected during the first 5 hospital days:

No non-culture tests done: Non-culture test data unknown:

No.	Collect Date (mm/dd/yy)	Specimen	Test	What pathogen(s) were tested for?	Result
1	____ / ___ / ___	Blood Lower resp Upper resp Urine Stool Other ______	PCR DFA Antigen test Other_____	Legionella Cdiff RSV Pneumococcus Adeno Influenza hMPV Paraflu Other ________ SARS-CoV-2	Negative Unknown Positive (insert code): Path1_______Path2_______ Path3_______
2	____ / ___ / ___	Blood Lower resp Upper resp Urine Stool Other ______	PCR DFA Antigen test Other_____	Legionella Cdiff RSV Pneumococcus Adeno Influenza hMPV Paraflu Other ________ SARS-CoV-2	Negative Unknown Positive (insert code): Path1_______Path2_______ Path3_______
3	____ / ___ / ___	Blood Lower resp Upper resp Urine Stool Other ______	PCR DFA Antigen test Other_____	Legionella Cdiff RSV Pneumococcus Adeno Influenza hMPV Paraflu Other ________ SARS-CoV-2	Negative Unknown Positive (insert code): Path1_______Path2_______ Path3_______
4	____ / ___ / ___	Blood Lower resp Upper resp Urine Stool Other ______	PCR DFA Antigen test Other_____	Legionella Cdiff RSV Pneumococcus Adeno Influenza hMPV Paraflu Other ________ SARS-CoV-2	Negative Unknown Positive (insert code): Path1_______Path2_______ Path3_______
5	____ / ___ / ___	Blood Lower resp Upper resp Urine Stool Other ______	PCR DFA Antigen test Other_____	Legionella Cdiff RSV Pneumococcus Adeno Influenza hMPV Paraflu Other ________ SARS-CoV-2	Negative Unknown Positive (insert code): Path1_______Path2_______ Path3_______

More tests than fit in the table:

HAI & ANTIMICROBIAL USE PREVALENCE SURVEY: ANTIMICROBIAL QUALITY ASSESSMENT (AQUA) FORM; 3d: UTI (Attachment_I_d_AQUA UTI_Form)

1. “Unknown” was added as an answer choice in question 1 of the form.

1. Check any of the following ICD-10 codes that were present on admission for this patient: None Unknown

N10 N11.0 N11.1 N11.8 N11.9 N12 N15.1 N15.9 N16 N28.84 N28.85 N28.86 N30.00 N30.01 N30.10 N30.11 N30.20 N30.21 N30.30 N30.31 N30.40 N30.41 N30.80 N30.81 N30.90 N30.91 N34.0 N34.1 N34.2 N39.0

R82.71 R82.90 N41.0 N41.1 N41.2 B37.49 O23.00 Other (specify): __________

2. “SARS-CoV-2” was added to the list of pathogens that were tested for in question 12 of the form.

12. Complete the table for non-culture tests (positive and negative) collected in the first 5 hospital days:

No non-culture tests done: Non-culture test data unknown:

No.	Collect Date (mm/dd/yy)	Specimen	Test	What pathogen(s) were tested for?	Result
1	___ / ___ / ___	Blood Lower resp Upper resp Urine Stool Other ______	PCR DFA Antigen test Other_____	Legionella Cdiff RSV Pneumococcus Adeno Influenza hMPV Paraflu Other ________ SARS-CoV-2	Negative Unknown Positive (insert code): Path1_______Path2_______ Path3_______
2	____ / ___ / ___	Blood Lower resp Upper resp Urine Stool Other ______	PCR DFA Antigen test Other_____	Legionella Cdiff RSV Pneumococcus Adeno Influenza hMPV Paraflu Other ________ SARS-CoV-2	Negative Unknown Positive (insert code): Path1_______Path2_______ Path3_______
3	____ / ___ / ___	Blood Lower resp Upper resp Urine Stool Other ______	PCR DFA Antigen test Other_____	Legionella Cdiff RSV Pneumococcus Adeno Influenza hMPV Paraflu Other ________ SARS-CoV-2	Negative Unknown Positive (insert code): Path1_______Path2_______ Path3_______
4	____ / ___ / ___	Blood Lower resp Upper resp Urine Stool Other ______	PCR DFA Antigen test Other_____	Legionella Cdiff RSV Pneumococcus Adeno Influenza hMPV Paraflu Other ________ SARS-CoV-2	Negative Unknown Positive (insert code): Path1_______Path2_______ Path3_______
5	____ / ___ / ___	Blood Lower resp Upper resp Urine Stool Other ______	PCR DFA Antigen test Other_____	Legionella Cdiff RSV Pneumococcus Adeno Influenza hMPV Paraflu Other ________ SARS-CoV-2	Negative Unknown Positive (insert code): Path1_______Path2_______ Path3_______

More tests than fit in the table:

HAI & ANTIMICROBIAL USE PREVALENCE SURVEY: HAI FORM (Attachment_E_HAI Form)

1. “ECLS” and “Hemodialysis catheter” were added under BSI section.

BSI

Check one: LCBI MBI-LCBI Central line-associated? Yes No Check all that apply: ECMO/ECLS VAD EB Self-injection in central line Hemodialysis catheter Munchausen syndrome (factitious disorder) Matching organism is identified in blood and from a site-specific specimen, both collected within the IWP and pus is present at ≥1 of the following vascular sites from which the specimen was collected: Arterial catheter Arteriovenous fistula Arteriovenous graft Atrial lines (Right and Left) Hemodialysis reliable outflow (HERO) catheter Peripheral IV or Midline catheter Intra-aortic balloon pump (IABP) device Non-accessed central line (not accessed nor inserted during the admission) None

____/____/____ or BH Unk

NA

____/____/___ Unk None

1: _______ 2: _______ 3: _______ or None

_________ Unk

2. USI was separated from UTI and make it a standalone HAI type.

UTI	Check one: SUTI ABUTI Catheter-associated? Yes No Was fever the only sign/symptom? Yes No Unknown Not applicable	____/____/____ or BH Unk	Yes No Unk	____/____/___ Unk None	1: _______ 2: _______ 3: _______ or None	_________ Unk
USI	Check one: USI	____/____/____ or BH Unk	Yes No Unk	____/____/___ Unk None	1: _______ 2: _______ 3: _______ or None	_________ Unk

3. Candida albicans and Candida parapsolosis were deleted and the list of antimicrobial drugs tested for Acinetobacter, Candida glabrata, Escherichia coli, Enterobacter cloacae, Klebsiella pneumoniae, Enterococcus faecalis, and Enterococcus faecium were updated to be consistent with NHSN case report forms.

Organism	HAI #1: _______, or NA	HAI #2: _______, or NA	HAI #3: _______, or NA	HAI #4: _______, or NA
Gram-negative
Acinetobacter (any species)	AMPSUL MERO/DORI S I R N S I R N CEFTAZ CEFEP S I R N S I R N COL/PB PIPTAZ S I R N S I R N IMI S I R N	AMPSUL MERO/DORI S I R N S I R N CEFTAZ CEFEP S I R N S I R N COL/PB PIPTAZ S I R N S I R N IMI S I R N	AMPSUL MERO/DORI S I R N S I R N CEFTAZ CEFEP S I R N S I R N COL/PB PIPTAZ S I R N S I R N IMI S I R N	AMPSUL MERO/DORI S I R N S I R N CEFTAZ CEFEP S I R N S I R N COL/PB PIPTAZ S I R N S I R N IMI S I R N
E. coli	ERTA PIPTAZ S I R N S I R N IMI IMIREL S I R N S I R N MERO/DORI MERVAB S I R N S I R N CEFEP S I R N CIPRO/LEVO/MOXI S I R N	ERTA PIPTAZ S I R N S I R N IMI IMIREL S I R N S I R N MERO/DORI MERVAB S I R N S I R N CEFEP S I R N CIPRO/LEVO/MOXI S I R N	ERTA PIPTAZ S I R N S I R N IMI IMIREL S I R N S I R N MERO/DORI MERVAB S I R N S I R N CEFEP S I R N CIPRO/LEVO/MOXI S I R N	ERTA PIPTAZ S I R N S I R N IMI IMIREL S I R N S I R N MERO/DORI MERVAB S I R N S I R N CEFEP S I R N CIPRO/LEVO/MOXI S I R N
Enterobacter cloacae	ERTA PIPTAZ S I R N S I R N IMI IMIREL S I R N S I R N MERO/DORI MERVAB S I R N S I R N CEFEP S I R N CIPRO/LEVO/MOXI S I R N	ERTA PIPTAZ S I R N S I R N IMI IMIREL S I R N S I R N MERO/DORI MERVAB S I R N S I R N CEFEP S I R N CIPRO/LEVO/MOXI S I R N	ERTA PIPTAZ S I R N S I R N IMI IMIREL S I R N S I R N MERO/DORI MERVAB S I R N S I R N CEFEP S I R N CIPRO/LEVO/MOXI S I R N	ERTA PIPTAZ S I R N S I R N IMI IMIREL S I R N S I R N MERO/DORI MERVAB S I R N S I R N CEFEP S I R N CIPRO/LEVO/MOXI S I R N
Klebsiella (Enterobacter) aerogenes Klebsiella oxytoca Klebsiella pneumoniae	ERTA PIPTAZ S I R N S I R N IMI IMIREL S I R N S I R N MERO/DORI MERVAB S I R N S I R N CEFEP S I R N CIPRO/LEVO/MOXI S I R N	ERTA PIPTAZ S I R N S I R N IMI IMIREL S I R N S I R N MERO/DORI MERVAB S I R N S I R N CEFEP S I R N CIPRO/LEVO/MOXI S I R N	ERTA PIPTAZ S I R N S I R N IMI IMIREL S I R N S I R N MERO/DORI MERVAB S I R N S I R N CEFEP S I R N CIPRO/LEVO/MOXI S I R N	ERTA PIPTAZ S I R N S I R N IMI IMIREL S I R N S I R N MERO/DORI MERVAB S I R N S I R N CEFEP S I R N CIPRO/LEVO/MOXI S I R N
Pseudomonas aeruginosa	CEFTAZ MERO/DORI S I R N S I R N COL/PB PIP/PIPTAZ S I R N S I R N GENT TOBRA S I R N S I R N IMI S I R N	CEFTAZ MERO/DORI S I R N S I R N COL/PB PIP/PIPTAZ S I R N S I R N GENT TOBRA S I R N S I R N IMI S I R N	CEFTAZ MERO/DORI S I R N S I R N COL/PB PIP/PIPTAZ S I R N S I R N GENT TOBRA S I R N S I R N IMI S I R N	CEFTAZ MERO/DORI S I R N S I R N COL/PB PIP/PIPTAZ S I R N S I R N GENT TOBRA S I R N S I R N IMI S I R N
Gram-positive
Staphylococcus aureus	CEFOX/METH/OX LNZ S I R N S R N DAPTO VANC S NS N S I R N	CEFOX/METH/OX LNZ S I R N S R N DAPTO VANC S NS N S I R N	CEFOX/METH/OX LNZ S I R N S R N DAPTO VANC S NS N S I R N	CEFOX/METH/OX LNZ S I R N S R N DAPTO VANC S NS N S I R N
Enterococcus faecalis Enterococcus faecium	DAPTO VANC S NS S-DD R N S I R N LNZ S I R N	DAPTO VANC S NS S-DD R N S I R N LNZ S I R N	DAPTO VANC S NS S-DD R N S I R N LNZ S I R N	DAPTO VANC S NS S-DD R N S I R N LNZ S I R N
Fungal
Candida glabrata	ANID MICA S I R N S I R N CASPO VORI S I R N S I R N FLUCO S S-DD R N	ANID MICA S I R N S I R N CASPO VORI S I R N S I R N FLUCO S S-DD R N	ANID MICA S I R N S I R N CASPO VORI S I R N S I R N FLUCO S S-DD R N	ANID MICA S I R N S I R N CASPO VORI S I R N S I R N FLUCO S S-DD R N

Form

Current question

Requested change

HAI & ANTIMICROBIAL USE PREVALENCE SURVEY ANTIMICROBIAL QUALITY ASSESSMENT (AQUA) FORM 2: GENERAL PATIENT ASSESSMENT

2. In the 30 days prior to admission to the survey hospital, did the patient receive (check all that apply):

IV antimicrobials Cancer chemotherapy Wound care Chronic hemodialysis Surgery

None Unknown

2. In the 30 days prior to admission to the survey hospital, did the patient receive (check all that apply):

IV antimicrobials Cancer chemotherapy Wound care Chronic hemodialysis Surgery

None Unknown COVID-19 specific treatment

HAI & ANTIMICROBIAL USE PREVALENCE SURVEY: ANTIMICROBIAL QUALITY ASSESSMENT (AQUA) FORM; 3a: VANCOMYCIN

6. Complete the table for non-culture microbiology tests (positive and negative) collected from 5 days before vancomycin IV first date through the vancomycin IV last date:

No non-culture tests done: Non-culture test data unknown:

No.	Collect date (mm/dd/yy)	Specimen	Test	What pathogen(s) were tested for?	Result
1	____ / ___ / ___	Blood Lower resp Upper resp Urine Stool Other ______	PCR DFA Antigen test Other_____	Legionella Cdiff RSV Pneumococcus Adeno Influenza hMPV Paraflu Other ________	Negative Unknown Positive (insert code): Path1_______Path2_______ Path3_______
2	____ / ___ / ___	Blood Lower resp Upper resp Urine Stool Other ______	PCR DFA Antigen test Other_____	Legionella Cdiff RSV Pneumococcus Adeno Influenza hMPV Paraflu Other ________	Negative Unknown Positive (insert code): Path1_______Path2_______ Path3_______
3	____ / ___ / ___	Blood Lower resp Upper resp Urine Stool Other ______	PCR DFA Antigen test Other_____	Legionella Cdiff RSV Pneumococcus Adeno Influenza hMPV Paraflu Other ________	Negative Unknown Positive (insert code): Path1_______Path2_______ Path3_______
4	____ / ___ / ___	Blood Lower resp Upper resp Urine Stool Other ______	PCR DFA Antigen test Other_____	Legionella Cdiff RSV Pneumococcus Adeno Influenza hMPV Paraflu Other ________	Negative Unknown Positive (insert code): Path1_______Path2_______ Path3_______
5	____ / ___ / ___	Blood Lower resp Upper resp Urine Stool Other ______	PCR DFA Antigen test Other_____	Legionella Cdiff RSV Pneumococcus Adeno Influenza hMPV Paraflu Other ________	Negative Unknown Positive (insert code): Path1_______Path2_______ Path3_______

More tests than fit in the table:

6. Complete the table for non-culture microbiology tests (positive and negative) collected from 5 days before vancomycin IV first date through the vancomycin IV last date:

No non-culture tests done: Non-culture test data unknown:

No.	Collect date (mm/dd/yy)	Specimen	Test	What pathogen(s) were tested for?	Result
1	____ / ___ / ___	Blood Lower resp Upper resp Urine Stool Other ______	PCR DFA Antigen test Other_____	Legionella Cdiff RSV Pneumococcus Adeno Influenza hMPV Paraflu Other ________ SARS-CoV-2	Negative Unknown Positive (insert code): Path1_______Path2_______ Path3_______
2	____ / ___ / ___	Blood Lower resp Upper resp Urine Stool Other ______	PCR DFA Antigen test Other_____	Legionella Cdiff RSV Pneumococcus Adeno Influenza hMPV Paraflu Other ________ SARS-CoV-2	Negative Unknown Positive (insert code): Path1_______Path2_______ Path3_______
3	____ / ___ / ___	Blood Lower resp Upper resp Urine Stool Other ______	PCR DFA Antigen test Other_____	Legionella Cdiff RSV Pneumococcus Adeno Influenza hMPV Paraflu Other ________ SARS-CoV-2	Negative Unknown Positive (insert code): Path1_______Path2_______ Path3_______
4	____ / ___ / ___	Blood Lower resp Upper resp Urine Stool Other ______	PCR DFA Antigen test Other_____	Legionella Cdiff RSV Pneumococcus Adeno Influenza hMPV Paraflu Other ________ SARS-CoV-2	Negative Unknown Positive (insert code): Path1_______Path2_______ Path3_______
5	____ / ___ / ___	Blood Lower resp Upper resp Urine Stool Other ______	PCR DFA Antigen test Other_____	Legionella Cdiff RSV Pneumococcus Adeno Influenza hMPV Paraflu Other ________ SARS-CoV-2	Negative Unknown Positive (insert code): Path1_______Path2_______ Path3_______

More tests than fit in the table:

HAI & ANTIMICROBIAL USE PREVALENCE SURVEY: ANTIMICROBIAL QUALITY ASSESSMENT (AQUA) FORM; 3b: FLUOROQUINOLONE

5. Complete the table for non-culture microbiology tests (positive and negative) collected from 5 days before fluoroquinolone first date through the fluoroquinolone last date:

No non-culture tests done: Non-culture test data unknown:

No.	Collect date (mm/dd/yy)	Specimen	Test	What pathogen(s) were tested for?	Result
1	____ / ___ / ___	Blood Lower resp Upper resp Urine Stool Other ______	PCR DFA Antigen test Other_____	Legionella Cdiff RSV Pneumococcus Adeno Influenza hMPV Paraflu Other ________	Negative Unknown Positive (insert code): Path1_______Path2_______ Path3_______
2	____ / ___ / ___	Blood Lower resp Upper resp Urine Stool Other ______	PCR DFA Antigen test Other_____	Legionella Cdiff RSV Pneumococcus Adeno Influenza hMPV Paraflu Other ________	Negative Unknown Positive (insert code): Path1_______Path2_______ Path3_______
3	____ / ___ / ___	Blood Lower resp Upper resp Urine Stool Other ______	PCR DFA Antigen test Other_____	Legionella Cdiff RSV Pneumococcus Adeno Influenza hMPV Paraflu Other ________	Negative Unknown Positive (insert code): Path1_______Path2_______ Path3_______
4	____ / ___ / ___	Blood Lower resp Upper resp Urine Stool Other ______	PCR DFA Antigen test Other_____	Legionella Cdiff RSV Pneumococcus Adeno Influenza hMPV Paraflu Other ________	Negative Unknown Positive (insert code): Path1_______Path2_______ Path3_______
5	____ / ___ / ___	Blood Lower resp Upper resp Urine Stool Other ______	PCR DFA Antigen test Other_____	Legionella Cdiff RSV Pneumococcus Adeno Influenza hMPV Paraflu Other ________	Negative Unknown Positive (insert code): Path1_______Path2_______ Path3_______

More tests than fit in the table:

5. Complete the table for non-culture microbiology tests (positive and negative) collected from 5 days before fluoroquinolone first date through the fluoroquinolone last date:

No non-culture tests done: Non-culture test data unknown:

No.	Collect date (mm/dd/yy)	Specimen	Test	What pathogen(s) were tested for?	Result
1	____ / ___ / ___	Blood Lower resp Upper resp Urine Stool Other ______	PCR DFA Antigen test Other_____	Legionella Cdiff RSV Pneumococcus Adeno Influenza hMPV Paraflu Other ________ SARS-CoV-2	Negative Unknown Positive (insert code): Path1_______Path2_______ Path3_______
2	____ / ___ / ___	Blood Lower resp Upper resp Urine Stool Other ______	PCR DFA Antigen test Other_____	Legionella Cdiff RSV Pneumococcus Adeno Influenza hMPV Paraflu Other ________ SARS-CoV-2	Negative Unknown Positive (insert code): Path1_______Path2_______ Path3_______
3	____ / ___ / ___	Blood Lower resp Upper resp Urine Stool Other ______	PCR DFA Antigen test Other_____	Legionella Cdiff RSV Pneumococcus Adeno Influenza hMPV Paraflu Other ________ SARS-CoV-2	Negative Unknown Positive (insert code): Path1_______Path2_______ Path3_______
4	____ / ___ / ___	Blood Lower resp Upper resp Urine Stool Other ______	PCR DFA Antigen test Other_____	Legionella Cdiff RSV Pneumococcus Adeno Influenza hMPV Paraflu Other ________ SARS-CoV-2	Negative Unknown Positive (insert code): Path1_______Path2_______ Path3_______
5	____ / ___ / ___	Blood Lower resp Upper resp Urine Stool Other ______	PCR DFA Antigen test Other_____	Legionella Cdiff RSV Pneumococcus Adeno Influenza hMPV Paraflu Other ________ SARS-CoV-2	Negative Unknown Positive (insert code): Path1_______Path2_______ Path3_______

More tests than fit in the table:

HAI & ANTIMICROBIAL USE PREVALENCE SURVEY: ANTIMICROBIAL QUALITY ASSESSMENT (AQUA) FORM; 3c: CAP

2. Check any of the following ICD-10 codes that were present on admission for this patient: None

J09.X1 J09.X2 J09.X3 J10.00 J10.01 J10.08 J10.1 J10.2 J10.81 J10.82 J10.83 J10.89 J11.00 J11.08 J11.1 J11.2 J11.81 J11.82 J11.83 J11.89 J12.0 J12.1 J12.2 J12.3 J12.81 J12.89 J12.9 J13 J14 J15.0 J15.1 J15.3 J15.4 J15.20 J15.211 J15.212 J15.29 J15.5 J15.6 J15.7 J15.8 J15.9 J16.0 J16.8 J18.0 J18.1 J18.9 A48.1 Other (specify):_____

3. Check any of the following ICD-10 codes that were present on admission for this patient: None Unknown

J09.X1 J09.X2 J09.X3 J10.00 J10.01 J10.08 J10.1 J10.2 J10.81 J10.82 J10.83 J10.89 J11.00 J11.08 J11.1 J11.2 J11.81 J11.82 J11.83 J11.89 J12.0 J12.1 J12.2 J12.3 J12.81 J12.89 J12.9 J13 J14 J15.0 J15.1 J15.3 J15.4 J15.20 J15.211 J15.212 J15.29 J15.5 J15.6 J15.7 J15.8 J15.9 J16.0 J16.8 J18.0 J18.1 J18.9 A48.1 Other (specify):_____

HAI & ANTIMICROBIAL USE PREVALENCE SURVEY: ANTIMICROBIAL QUALITY ASSESSMENT (AQUA) FORM; 3c: CAP

13. Complete the table for non-culture microbiology tests (positive and negative) collected during the first 5 hospital days:

No non-culture tests done: Non-culture test data unknown:

No.	Collect Date (mm/dd/yy)	Specimen	Test	What pathogen(s) were tested for?	Result
1	____ / ___ / ___	Blood Lower resp Upper resp Urine Stool Other ______	PCR DFA Antigen test Other_____	Legionella Cdiff RSV Pneumococcus Adeno Influenza hMPV Paraflu Other ________	Negative Unknown Positive (insert code): Path1_______Path2_______ Path3_______
2	____ / ___ / ___	Blood Lower resp Upper resp Urine Stool Other ______	PCR DFA Antigen test Other_____	Legionella Cdiff RSV Pneumococcus Adeno Influenza hMPV Paraflu Other ________	Negative Unknown Positive (insert code): Path1_______Path2_______ Path3_______
3	____ / ___ / ___	Blood Lower resp Upper resp Urine Stool Other ______	PCR DFA Antigen test Other_____	Legionella Cdiff RSV Pneumococcus Adeno Influenza hMPV Paraflu Other ________	Negative Unknown Positive (insert code): Path1_______Path2_______ Path3_______
4	____ / ___ / ___	Blood Lower resp Upper resp Urine Stool Other ______	PCR DFA Antigen test Other_____	Legionella Cdiff RSV Pneumococcus Adeno Influenza hMPV Paraflu Other ________	Negative Unknown Positive (insert code): Path1_______Path2_______ Path3_______
5	____ / ___ / ___	Blood Lower resp Upper resp Urine Stool Other ______	PCR DFA Antigen test Other_____	Legionella Cdiff RSV Pneumococcus Adeno Influenza hMPV Paraflu Other ________	Negative Unknown Positive (insert code): Path1_______Path2_______ Path3_______

More tests than fit in the table:

13. Complete the table for non-culture microbiology tests (positive and negative) collected during the first 5 hospital days:

No non-culture tests done: Non-culture test data unknown:

No.	Collect Date (mm/dd/yy)	Specimen	Test	What pathogen(s) were tested for?	Result
1	____ / ___ / ___	Blood Lower resp Upper resp Urine Stool Other ______	PCR DFA Antigen test Other_____	Legionella Cdiff RSV Pneumococcus Adeno Influenza hMPV Paraflu Other ________ SARS-CoV-2	Negative Unknown Positive (insert code): Path1_______Path2_______ Path3_______
2	____ / ___ / ___	Blood Lower resp Upper resp Urine Stool Other ______	PCR DFA Antigen test Other_____	Legionella Cdiff RSV Pneumococcus Adeno Influenza hMPV Paraflu Other ________ SARS-CoV-2	Negative Unknown Positive (insert code): Path1_______Path2_______ Path3_______
3	____ / ___ / ___	Blood Lower resp Upper resp Urine Stool Other ______	PCR DFA Antigen test Other_____	Legionella Cdiff RSV Pneumococcus Adeno Influenza hMPV Paraflu Other ________ SARS-CoV-2	Negative Unknown Positive (insert code): Path1_______Path2_______ Path3_______
4	____ / ___ / ___	Blood Lower resp Upper resp Urine Stool Other ______	PCR DFA Antigen test Other_____	Legionella Cdiff RSV Pneumococcus Adeno Influenza hMPV Paraflu Other ________ SARS-CoV-2	Negative Unknown Positive (insert code): Path1_______Path2_______ Path3_______
5	____ / ___ / ___	Blood Lower resp Upper resp Urine Stool Other ______	PCR DFA Antigen test Other_____	Legionella Cdiff RSV Pneumococcus Adeno Influenza hMPV Paraflu Other ________ SARS-CoV-2	Negative Unknown Positive (insert code): Path1_______Path2_______ Path3_______

More tests than fit in the table:

HAI & ANTIMICROBIAL USE PREVALENCE SURVEY: ANTIMICROBIAL QUALITY ASSESSMENT (AQUA) FORM; 3d: UTI

1. Check any of the following ICD-10 codes that were present on admission for this patient: None

N10 N11.0 N11.1 N11.8 N11.9 N12 N15.1 N15.9 N16 N28.84 N28.85 N28.86 N30.00 N30.01 N30.10 N30.11 N30.20 N30.21 N30.30 N30.31 N30.40 N30.41 N30.80 N30.81 N30.90 N30.91 N34.0 N34.1 N34.2 N39.0

R82.71 R82.90 N41.0 N41.1 N41.2 B37.49 O23.00 Other (specify): __________

1. Check any of the following ICD-10 codes that were present on admission for this patient: None Unknown

N10 N11.0 N11.1 N11.8 N11.9 N12 N15.1 N15.9 N16 N28.84 N28.85 N28.86 N30.00 N30.01 N30.10 N30.11 N30.20 N30.21 N30.30 N30.31 N30.40 N30.41 N30.80 N30.81 N30.90 N30.91 N34.0 N34.1 N34.2 N39.0

R82.71 R82.90 N41.0 N41.1 N41.2 B37.49 O23.00 Other (specify): __________

HAI & ANTIMICROBIAL USE PREVALENCE SURVEY: ANTIMICROBIAL QUALITY ASSESSMENT (AQUA) FORM; 3d: UTI

12. Complete the table for non-culture tests (positive and negative) collected in the first 5 hospital days:

No non-culture tests done: Non-culture test data unknown:

No.	Collect Date (mm/dd/yy)	Specimen	Test	What pathogen(s) were tested for?	Result
1	___ / ___ / ___	Blood Lower resp Upper resp Urine Stool Other ______	PCR DFA Antigen test Other_____	Legionella Cdiff RSV Pneumococcus Adeno Influenza hMPV Paraflu Other ________ SARS-CoV-2	Negative Unknown Positive (insert code): Path1_______Path2_______ Path3_______
2	____ / ___ / ___	Blood Lower resp Upper resp Urine Stool Other ______	PCR DFA Antigen test Other_____	Legionella Cdiff RSV Pneumococcus Adeno Influenza hMPV Paraflu Other ________ SARS-CoV-2	Negative Unknown Positive (insert code): Path1_______Path2_______ Path3_______
3	____ / ___ / ___	Blood Lower resp Upper resp Urine Stool Other ______	PCR DFA Antigen test Other_____	Legionella Cdiff RSV Pneumococcus Adeno Influenza hMPV Paraflu Other ________ SARS-CoV-2	Negative Unknown Positive (insert code): Path1_______Path2_______ Path3_______
4	____ / ___ / ___	Blood Lower resp Upper resp Urine Stool Other ______	PCR DFA Antigen test Other_____	Legionella Cdiff RSV Pneumococcus Adeno Influenza hMPV Paraflu Other ________ SARS-CoV-2	Negative Unknown Positive (insert code): Path1_______Path2_______ Path3_______
5	____ / ___ / ___	Blood Lower resp Upper resp Urine Stool Other ______	PCR DFA Antigen test Other_____	Legionella Cdiff RSV Pneumococcus Adeno Influenza hMPV Paraflu Other ________ SARS-CoV-2	Negative Unknown Positive (insert code): Path1_______Path2_______ Path3_______

More tests than fit in the table:

12. Complete the table for non-culture tests (positive and negative) collected in the first 5 hospital days:

No non-culture tests done: Non-culture test data unknown:

No.	Collect Date (mm/dd/yy)	Specimen	Test	What pathogen(s) were tested for?	Result
1	___ / ___ / ___	Blood Lower resp Upper resp Urine Stool Other ______	PCR DFA Antigen test Other_____	Legionella Cdiff RSV Pneumococcus Adeno Influenza hMPV Paraflu Other ________ SARS-CoV-2	Negative Unknown Positive (insert code): Path1_______Path2_______ Path3_______
2	____ / ___ / ___	Blood Lower resp Upper resp Urine Stool Other ______	PCR DFA Antigen test Other_____	Legionella Cdiff RSV Pneumococcus Adeno Influenza hMPV Paraflu Other ________ SARS-CoV-2	Negative Unknown Positive (insert code): Path1_______Path2_______ Path3_______
3	____ / ___ / ___	Blood Lower resp Upper resp Urine Stool Other ______	PCR DFA Antigen test Other_____	Legionella Cdiff RSV Pneumococcus Adeno Influenza hMPV Paraflu Other ________ SARS-CoV-2	Negative Unknown Positive (insert code): Path1_______Path2_______ Path3_______
4	____ / ___ / ___	Blood Lower resp Upper resp Urine Stool Other ______	PCR DFA Antigen test Other_____	Legionella Cdiff RSV Pneumococcus Adeno Influenza hMPV Paraflu Other ________ SARS-CoV-2	Negative Unknown Positive (insert code): Path1_______Path2_______ Path3_______
5	____ / ___ / ___	Blood Lower resp Upper resp Urine Stool Other ______	PCR DFA Antigen test Other_____	Legionella Cdiff RSV Pneumococcus Adeno Influenza hMPV Paraflu Other ________ SARS-CoV-2	Negative Unknown Positive (insert code): Path1_______Path2_______ Path3_______

More tests than fit in the table:

HAI & ANTIMICROBIAL USE PREVALENCE SURVEY: HAI FORM

BSI

Check one: LCBI MBI-LCBI Central line-associated? Yes No Check all that apply: ECMO VAD EB Self-injection in central line Munchausen syndrome (factitious disorder) Matching organism is identified in blood and from a site-specific specimen, both collected within the IWP and pus is present at ≥1 of the following vascular sites from which the specimen was collected: Arterial catheter Arteriovenous fistula Arteriovenous graft Atrial lines (Right and Left) Hemodialysis reliable outflow (HERO) catheter Peripheral IV or Midline catheter Intra-aortic balloon pump (IABP) device Non-accessed central line (not accessed nor inserted during the admission) None

____/____/____ or BH Unk

NA

____/____/___ Unk None

1: _______ 2: _______ 3: _______ or None

_________ Unk

BSI

Check one: LCBI MBI-LCBI Central line-associated? Yes No Check all that apply: ECMO/ECLS VAD EB Self-injection in central line Hemodialysis catheter Munchausen syndrome (factitious disorder) Matching organism is identified in blood and from a site-specific specimen, both collected within the IWP and pus is present at ≥1 of the following vascular sites from which the specimen was collected: Arterial catheter Arteriovenous fistula Arteriovenous graft Atrial lines (Right and Left) Hemodialysis reliable outflow (HERO) catheter Peripheral IV or Midline catheter Intra-aortic balloon pump (IABP) device Non-accessed central line (not accessed nor inserted during the admission) None

____/____/____ or BH Unk

NA

____/____/___ Unk None

1: _______ 2: _______ 3: _______ or None

_________ Unk

HAI & ANTIMICROBIAL USE PREVALENCE SURVEY: HAI FORM

UTI

Check one: SUTI ABUTI Catheter-associated? Yes No Was fever the only sign/symptom? Yes No Unknown Not applicable

____/____/____ or BH Unk

Yes No Unk

____/____/___ Unk None

1: _______ 2: _______ 3: _______ or None

_________ Unk

UTI	Check one: SUTI ABUTI Catheter-associated? Yes No Was fever the only sign/symptom? Yes No Unknown Not applicable	____/____/____ or BH Unk	Yes No Unk	____/____/___ Unk None	1: _______ 2: _______ 3: _______ or None	_________ Unk
USI	Check one: USI	____/____/____ or BH Unk	Yes No Unk	____/____/___ Unk None	1: _______ 2: _______ 3: _______ or None	_________ Unk

Organism	HAI #1: _______, or NA		HAI #2: _______, or NA		HAI #3: _______, or NA		HAI #4: _______, or NA
Acinetobacter (any species)	AMPSUL CEFTAZ COL/PB IMI MERO/DORI TIG	S I R N S I R N S I R N S I R N S I R N S I R N	AMPSUL CEFTAZ COL/PB IMI MERO/DORI TIG	S I R N S I R N S I R N S I R N S I R N S I R N	AMPSUL CEFTAZ COL/PB IMI MERO/DORI TIG	S I R N S I R N S I R N S I R N S I R N S I R N	AMPSUL CEFTAZ COL/PB IMI MERO/DORI TIG	S I R N S I R N S I R N S I R N S I R N S I R N
Candida albicans	ANID CASPO FLUCO MICA	S I R N S I R N S S-DD R N S I R N	ANID CASPO FLUCO MICA	S I R N S I R N S S-DD R N S I R N	ANID CASPO FLUCO MICA	S I R N S I R N S S-DD R N S I R N	ANID CASPO FLUCO MICA	S I R N S I R N S S-DD R N S I R N
Candida glabrata	ANID CASPO FLUCO MICA	S I R N S I R N S S-DD R N S I R N	ANID CASPO FLUCO MICA	S I R N S I R N S S-DD R N S I R N	ANID CASPO FLUCO MICA	S I R N S I R N S S-DD R N S I R N	ANID CASPO FLUCO MICA	S I R N S I R N S S-DD R N S I R N
Candida parapsilosis	ANID CASPO FLUCO MICA	S I R N S I R N S S-DD R N S I R N	ANID CASPO FLUCO MICA	S I R N S I R N S S-DD R N S I R N	ANID CASPO FLUCO MICA	S I R N S I R N S S-DD R N S I R N	ANID CASPO FLUCO MICA	S I R N S I R N S S-DD R N S I R N
E. coli	ERTA IMI MERO/DORI	S I R N S I R N S I R N	ERTA IMI MERO/DORI	S I R N S I R N S I R N	ERTA IMI MERO/DORI	S I R N S I R N S I R N	ERTA IMI MERO/DORI	S I R N S I R N S I R N
Enterobacter cloacae	ERTA IMI MERO/DORI	S I R N S I R N S I R N	ERTA IMI MERO/DORI	S I R N S I R N S I R N	ERTA IMI MERO/DORI	S I R N S I R N S I R N	ERTA IMI MERO/DORI	S I R N S I R N S I R N
Enterococcus faecalis	DAPTO LNZ VANC	S NS N S I R N S I R N	DAPTO LNZ VANC	S NS N S I R N S I R N	DAPTO LNZ VANC	S NS N S I R N S I R N	DAPTO LNZ VANC	S NS N S I R N S I R N
Enterococcus faecium	DAPTO LNZ VANC	S NS N S I R N S I R N	DAPTO LNZ VANC	S NS N S I R N S I R N	DAPTO LNZ VANC	S NS N S I R N S I R N	DAPTO LNZ VANC	S NS N S I R N S I R N
Klebsiella (Enterobacter) aerogenes	ERTA IMI MERO/DORI	S I R N S I R N S I R N	ERTA IMI MERO/DORI	S I R N S I R N S I R N	ERTA IMI MERO/DORI	S I R N S I R N S I R N	ERTA IMI MERO/DORI	S I R N S I R N S I R N
Klebsiella oxytoca	ERTA IMI MERO/DORI	S I R N S I R N S I R N	ERTA IMI MERO/DORI	S I R N S I R N S I R N	ERTA IMI MERO/DORI	S I R N S I R N S I R N	ERTA IMI MERO/DORI	S I R N S I R N S I R N
Klebsiella pneumoniae	ERTA IMI MERO/DORI	S I R N S I R N S I R N	ERTA IMI MERO/DORI	S I R N S I R N S I R N	ERTA IMI MERO/DORI	S I R N S I R N S I R N	ERTA IMI MERO/DORI	S I R N S I R N S I R N
Pseudomonas aeruginosa	CEFTAZ COL/PB GENT IMI MERO/DORI PIP/PIPTAZ TOBRA	S I R N S I R N S I R N S I R N S I R N S I R N S I R N	CEFTAZ COL/PB GENT IMI MERO/DORI PIP/PIPTAZ TOBRA	S I R N S I R N S I R N S I R N S I R N S I R N S I R N	CEFTAZ COL/PB GENT IMI MERO/DORI PIP/PIPTAZ TOBRA	S I R N S I R N S I R N S I R N S I R N S I R N S I R N	CEFTAZ COL/PB GENT IMI MERO/DORI PIP/PIPTAZ TOBRA	S I R N S I R N S I R N S I R N S I R N S I R N S I R N
Staphylococcus aureus	CEFOX/ METH/OX DAPTO LNZ VANC	S I R N S NS N S R N S I R N	CEFOX/ METH/OX DAPTO LNZ VANC	S I R N S NS N S R N S I R N	CEFOX/ METH/OX DAPTO LNZ VANC	S I R N S NS N S R N S I R N	CEFOX/ METH/OX DAPTO LNZ VANC	S I R N S NS N S R N S I R N

Organism	HAI #1: _______, or NA	HAI #2: _______, or NA	HAI #3: _______, or NA	HAI #4: _______, or NA
Gram-negative
Acinetobacter (any species)	AMPSUL MERO/DORI S I R N S I R N CEFTAZ CEFEP S I R N S I R N COL/PB PIPTAZ S I R N S I R N IMI S I R N	AMPSUL MERO/DORI S I R N S I R N CEFTAZ CEFEP S I R N S I R N COL/PB PIPTAZ S I R N S I R N IMI S I R N	AMPSUL MERO/DORI S I R N S I R N CEFTAZ CEFEP S I R N S I R N COL/PB PIPTAZ S I R N S I R N IMI S I R N	AMPSUL MERO/DORI S I R N S I R N CEFTAZ CEFEP S I R N S I R N COL/PB PIPTAZ S I R N S I R N IMI S I R N
E. coli	ERTA PIPTAZ S I R N S I R N IMI IMIREL S I R N S I R N MERO/DORI MERVAB S I R N S I R N CEFEP S I R N CIPRO/LEVO/MOXI S I R N	ERTA PIPTAZ S I R N S I R N IMI IMIREL S I R N S I R N MERO/DORI MERVAB S I R N S I R N CEFEP S I R N CIPRO/LEVO/MOXI S I R N	ERTA PIPTAZ S I R N S I R N IMI IMIREL S I R N S I R N MERO/DORI MERVAB S I R N S I R N CEFEP S I R N CIPRO/LEVO/MOXI S I R N	ERTA PIPTAZ S I R N S I R N IMI IMIREL S I R N S I R N MERO/DORI MERVAB S I R N S I R N CEFEP S I R N CIPRO/LEVO/MOXI S I R N
Enterobacter cloacae	ERTA PIPTAZ S I R N S I R N IMI IMIREL S I R N S I R N MERO/DORI MERVAB S I R N S I R N CEFEP S I R N CIPRO/LEVO/MOXI S I R N	ERTA PIPTAZ S I R N S I R N IMI IMIREL S I R N S I R N MERO/DORI MERVAB S I R N S I R N CEFEP S I R N CIPRO/LEVO/MOXI S I R N	ERTA PIPTAZ S I R N S I R N IMI IMIREL S I R N S I R N MERO/DORI MERVAB S I R N S I R N CEFEP S I R N CIPRO/LEVO/MOXI S I R N	ERTA PIPTAZ S I R N S I R N IMI IMIREL S I R N S I R N MERO/DORI MERVAB S I R N S I R N CEFEP S I R N CIPRO/LEVO/MOXI S I R N
Klebsiella (Enterobacter) aerogenes Klebsiella oxytoca Klebsiella pneumoniae	ERTA PIPTAZ S I R N S I R N IMI IMIREL S I R N S I R N MERO/DORI MERVAB S I R N S I R N CEFEP S I R N CIPRO/LEVO/MOXI S I R N	ERTA PIPTAZ S I R N S I R N IMI IMIREL S I R N S I R N MERO/DORI MERVAB S I R N S I R N CEFEP S I R N CIPRO/LEVO/MOXI S I R N	ERTA PIPTAZ S I R N S I R N IMI IMIREL S I R N S I R N MERO/DORI MERVAB S I R N S I R N CEFEP S I R N CIPRO/LEVO/MOXI S I R N	ERTA PIPTAZ S I R N S I R N IMI IMIREL S I R N S I R N MERO/DORI MERVAB S I R N S I R N CEFEP S I R N CIPRO/LEVO/MOXI S I R N
Pseudomonas aeruginosa	CEFTAZ MERO/DORI S I R N S I R N COL/PB PIP/PIPTAZ S I R N S I R N GENT TOBRA S I R N S I R N IMI S I R N	CEFTAZ MERO/DORI S I R N S I R N COL/PB PIP/PIPTAZ S I R N S I R N GENT TOBRA S I R N S I R N IMI S I R N	CEFTAZ MERO/DORI S I R N S I R N COL/PB PIP/PIPTAZ S I R N S I R N GENT TOBRA S I R N S I R N IMI S I R N	CEFTAZ MERO/DORI S I R N S I R N COL/PB PIP/PIPTAZ S I R N S I R N GENT TOBRA S I R N S I R N IMI S I R N
Gram-positive
Staphylococcus aureus	CEFOX/METH/OX LNZ S I R N S R N DAPTO VANC S NS N S I R N	CEFOX/METH/OX LNZ S I R N S R N DAPTO VANC S NS N S I R N	CEFOX/METH/OX LNZ S I R N S R N DAPTO VANC S NS N S I R N	CEFOX/METH/OX LNZ S I R N S R N DAPTO VANC S NS N S I R N
Enterococcus faecalis Enterococcus faecium	DAPTO VANC S NS S-DD R N S I R N LNZ S I R N	DAPTO VANC S NS S-DD R N S I R N LNZ S I R N	DAPTO VANC S NS S-DD R N S I R N LNZ S I R N	DAPTO VANC S NS S-DD R N S I R N LNZ S I R N
Fungal
Candida glabrata	ANID MICA S I R N S I R N CASPO VORI S I R N S I R N FLUCO S S-DD R N	ANID MICA S I R N S I R N CASPO VORI S I R N S I R N FLUCO S S-DD R N	ANID MICA S I R N S I R N CASPO VORI S I R N S I R N FLUCO S S-DD R N	ANID MICA S I R N S I R N CASPO VORI S I R N S I R N FLUCO S S-DD R N