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

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

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