Patient Information Form (PIF) (modified August 2022)

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

Att_D_PIF_Aug22

OMB: 0920-0852

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Form Approved

OMB No. 0920-0852

Exp. Date 03/31/2025


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): ______ / ______ / __________

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.: ____________________________


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 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



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: ____ / ____ / _________

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_ 20220516 Page 1 of 2

File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
AuthorShelley Magill
File Modified0000-00-00
File Created2023-08-28

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