Form
Approved
OMB No. 0920-0666
Exp. Date: xx/xx/20xx
www.cdc.gov/nhsn
Laboratory-identified MDRO or CDI Event
Instructions for this form are available at: http://www.cdc.gov/nhsn/forms/instr/57_128.pdf
Laboratory-identified MDRO or CDI Event
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*required for saving **conditionally required |
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Event Details (continued) |
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*Outpatient: |
□ Yes |
□ No |
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*Specimen Body Site/System: |
*Specimen Source: |
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*Date Admitted to Facility: __________ |
*Location: |
*Date Admitted to Location: __________ |
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**Last physical overnight location of patient immediately prior to arriving into facility (applies to specimen(s) collected in outpatient setting or <4 days after inpatient admission) (Check one): |
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□ Nursing Home/Skilled Nursing Facility |
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□ Personal residence/Residential care |
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□ Other Inpatient Healthcare Setting (i.e., acute care hospital, IRF, LTAC, etc.) |
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□ Unknown |
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*Has patient been discharged from your facility in the past 4 weeks? |
□ Yes |
□ No |
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If Yes, date of last discharge from your facility:_____________ |
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*Has patient been discharged from another facility in the past 4 weeks? |
□ Yes |
□ No |
□ Unknown |
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If Yes, from where (Check all that apply): |
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□ Nursing Home/Skilled Nursing Facility |
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□ Other Inpatient Healthcare Setting (i.e., acute care hospital, IRF, LTAC, etc.) |
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Custom Fields |
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Label |
Label |
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____/____/____ |
_______________________ |
____/____/____ |
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_______________________ |
_____________ |
_______________________ |
_____________ |
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_______________________ |
_____________ |
_______________________ |
_____________ |
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_______________________ |
_____________ |
_______________________ |
_____________ |
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Comments |
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File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
Author | Amy Schneider |
File Modified | 0000-00-00 |
File Created | 2023-08-23 |