Form 4 AR Lab Network Alert Report Form for Bacterial Specimen

Form Approved

OMB Control No.: 0920-1310

Expiration date: XX/XX/XXXX

ARLN Alert Form

Submitting State Laboratory ID

Date alert sent from jurisdiction to CDC

Which state is submitting this alert?

From which state did the isolate originate?

Alert type

Alert type other, specify

Was this pan resistant? (non-susceptible to all drugs tested thus far)

Was this isolate sent to regional laboratory for testing?

Original submitting State Laboratory ID

Specimen source

Patient age in years

Date of specimen collection

Organism (Genera)

Other genus, specify

Species

mCIM or Carba-NP results?

KPC Result

NDM Result

OXA-48 Result

OXA-23, -24/40, 58-like Result

VIM Result

IMP Result

Which method(s) was used to test IMP?

By which method was IMP positive?

mcr-1 Result

mcr-2 Result

Other genes detected

Other genes detected, specify

Description of AST for the isolate?

AST file from submitting lab

AST from submitting clinical lab

AST from public health lab

Which method was used to conduct AST at Public Health Laboratory?

AST result for Amikacin

AST result for Ticarcillin/clavulanic acid constant 2

AST result for Aztreonam

AST result for Cefepime

AST result for Piperacillin/tazobactam constant 4

AST result for Trimethoprim/sulfamethoxazole

AST result for Gentamicin

AST result for Cefepime

AST result for Tobramycin

AST result for Levofloxacin

AST result for Doxycycline

AST result for Ciprofloxacin

AST result for Minocycline

AST result for Meropenem

AST result for Doripenem

AST result for Colistin

AST result for Polymixin B

AST result for Ceftazidime

AST result for Cefotaxime

AST result for Tigecycline

AST result for Ertapenem

AST result for Imipenem

AST result for Cefazolin

AST result for Ceftriaxone

AST result for Amoxicillin/Clavulanic acid

AST result for Ampicillin

AST result for Ampicillin/Sulbactam

AST result for Nitrofurantoin

AST result for Ceftazidime Avibactam

AST result for Ceftolozane/tazobactam

AST result for Moxifloxacin

AST results from Regional lab

Was the specimen detected during colonization screening?

State lab ID of the Index patient (isolate)

Any other information about the isolate/patient you would like to us to know?

Public reporting burden of this collection of information is estimated to average 6 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 Reports Clearance Officer, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA 0920-1310