Patient Information Form (PIF) (August 2022 changes in tracked-change format)

Att_D_PIF_tracked_Aug22.docx

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

Patient Information Form (PIF) (August 2022 changes in tracked-change format)

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: __________ZIP: __________State: __________ City:________________________________

Address type: (check one)

 FORMCHECKBOX Other FORMCHECKBOX 

 FORMCHECKBOX Insufficient  FORMCHECKBOX 

 FORMCHECKBOX Missing FORMCHECKBOX 

 FORMCHECKBOX

 FORMCHECKBOX Military

 FORMCHECKBOX

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

 FORMCHECKBOX

Race: (check all that apply)

American Indian or Alaska Native  FORMCHECKBOX

Asian Not Documented FORMCHECKBOX


















FORMCHECKBOX 

 FORMCHECKBOX 



 FORMCHECKBOX  FORMCHECKBOX 

 FORMCHECKBOX  FORMCHECKBOX 

 FORMCHECKBOX 

 FORMCHECKBOX 



 FORMCHECKBOX 

 FORMCHECKBOX 


 FORMCHECKBOX



FORMCHECKBOX







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File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
AuthorShelley Magill
File Modified0000-00-00
File Created2022-08-04

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