Form 0920-0978 MuGSI SO Survey Questionnaire

Form approved
OMB No. xxxx-xxxx
Expires xx/xx/xxxx

2021 HAIC Multi-site Gram-negative Surveillance Initiative (MuGSI) Supplemental Surveillance
Officer Survey
Please answer the following questions for the year 2021. The purpose of the survey is to verify and
document current surveillance procedures, including isolate collection and testing methods at clinical
laboratories. Please enter your responses into the corresponding RedCap database. If you have any
questions, please contact Julian Grass ([email protected]) and Jigsa Tola ([email protected]).

Site: ___ CA ___ CO ___ CT ___ GA ___ MD ___ MN ___ NM ___ NY ___ OR ___ TN
Person(s) Completing the Form: ___________________________
Please note that the information collected in the sections below about specific MuGSI pathogens should
only be completed for those sites that participate in those surveillance activities.
Surveillance Area Characteristics
1.

What counties are under surveillance for MuGSI activities at your site?
a. Carbapenem-resistant Enterobacterales (CRE) surveillance catchment area, please
specify:_________________________________
b. Carbapenem-resistant Acinetobacter baumannii (CRAB) surveillance catchment area,
please specify:_______________________________
c. Extended-spectrum β-lactamases (ESBL)-producing Enterobacterales surveillance
catchment area, please specify:________________________________

2. Is CRE state reportable at your site? ___ yes

___ no

a. If yes:
i. Please describe your state reportable definition of CRE:______________
ii. What is the catchment area where CRE is reportable at your site?
_______ Statewide
_______ Defined catchment area, please specify__________
iii. Is isolate submission to the State Health Department Laboratory required?
_______ yes
_______ no
b. If no:
i. What mechanism do you have in place that allows for SOs to have access to CRE
case counts and medical records?
_______ Agent of the state
_______ State Health Department Regulation
_______ Other, please explain: __________________________________
ii. Does your state/site plan to make CRE reportable? ___ yes ___ no
3.

Is CRAB state reportable at your site? ___ yes

___ no

Public reporting burden of this collection of information is estimated to average 15 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 current valid OMB control number. Send comments rega rding 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 Rd NE, MS D-74, Atlanta, Georgia 30329;
ATTN: PRA (xxxx-xxxx)

a. If yes:
i. Please describe your state reportable definition of CRAB:______________
ii. What is the catchment area where CRAB is reportable at your site?
_______ Statewide
_______ Defined catchment area, please specify__________
iii. Is isolate submission to the State Health Department Laboratory required?
_______ yes
_______ no
b. If no:
i. What mechanism do you have in place that allows for SOs to have access to
CRAB case counts and medical records?
_______ Agent of the state
_______ State Health Department Regulation
_______ Other, please explain: __________________________________
ii. Does your state/site plan to make CRAB reportable? ___ yes ___ no
4. Is ESBL state reportable at your site? ___ yes

___ no

a. If yes:
i. Please describe your state reportable definition of ESBL:______________
ii. What is the catchment area where ESBL is reportable at your site?
_______ Statewide
_______ Defined catchment area, please specify__________
iii. Is isolate submission to the State Health Department Laboratory required?
_______ yes
_______ no
b. If no:
i. What mechanism do you have in place that allows for SOs to have access to
ESBL case counts and medical records?
_______ Agent of the state
_______ State Health Department Regulation
_______ Other, please explain: __________________________________
ii. Does your state/site plan to make ESBL reportable? ___ yes ___ no
Lab Participation and Isolate Testing
1. Please describe the clinical laboratories in the MuGSI catchment area:
a. CRE
i. Proportion of clinical laboratories serving that catchment area that participate in
MuGSI CRE surveillance: ___________________
ii. Number of clinical laboratories serving the catchment area that participate in
MuGSI CRE surveillance with queries installed on their automated testing
instrument (ATI) or laboratory information system (LIS): ___________________
iii. Total number of clinical laboratories serving the MuGSI CRE catchment

area:______________
iv. Please describe how MuGSI CRE surveillance is conducted at laboratories where
ATI/LIS queries are not installed (e.g., HL7 messages from
LabCorp):_______________________________________
b. CRAB
i. Proportion of clinical laboratories serving that catchment area that participate in
MuGSI CRAB surveillance: ___________________
ii. Number of clinical laboratories serving the catchment area that participate in
MuGSI CRAB surveillance with queries installed on their ATI or LIS:
___________________
iii. Total number of clinical laboratories serving the MuGSI CRAB catchment
area:______________
iv. Please describe how MuGSI CRAB surveillance is conducted at laboratories
where ATI/LIS queries are not installed (e.g., HL7 messages from
LabCorp):_________________________________
c. ESBL
i. Proportion of clinical laboratories serving that catchment area that participate in
MuGSI ESBL surveillance: ___________________
ii. Number of clinical laboratories serving the catchment area that participate in
MuGSI ESBL surveillance with queries installed on their ATI or LIS:
___________________
iii. Total number of clinical laboratories serving the MuGSI ESBL catchment
area:______________
iv. Please describe how MuGSI ESBL surveillance is conducted at laboratories
where ATI/LIS queries are not installed (e.g., HL7 messages from
LabCorp):_________________________________
2. Did your site send MuGSI isolates to CDC for characterization in 2021? ____yes ____no
a. If yes, please describe the sampling strategy for MuGSI isolates sent to CDC:
i. CRE: _____________________________________________________________
ii. CRAB: ___________________________________________________________
iii. ESBL: ____________________________________________________________
b. If yes, how many clinical laboratories contribute MuGSI isolates:
i. CRE: _____________________________________________________________
ii. CRAB: ___________________________________________________________
iii. ESBL: ____________________________________________________________
c. If yes, how many isolates did you expect to be able to collect from the clinical
laboratories in 2021?
_______ CRE; _______ CRAB; _______ ESBL
d. If yes, what was the total number of isolates collected from the clinical laboratories in
2021?
_______ CRE; _______ CRAB; _______ ESBL

Form approved
OMB No. xxxx-xxxx
Expires xx/xx/xxxx

Please complete the following table for each clinical laboratory participating in MuGSI surveillance at your site in 2021:
EIP
site

Lab
ID

Type of
Laboratory

MuGSI
pathogen(s) under
surveillance

Method for
case
identification

Type of
ATI
and
card

Carbapenem
confirmatory
testing and
method (if
available)*¶

Carbapenemase
testing and
method (if
available)*¶

ESBL
production
testing and
method¶

Organism
identification
method†

Cultureindependent
diagnostic
test

Isolate
submission
to state
public health
laboratory

*If this information is not available at the time of completing this survey, we encourage you to include it in your next check in with the
laboratory.
¶Additionally, please indicate the specific isolates that undergo this testing.
†Indicate the type of instrument and database/library
Additional information on MuGSI surveillance activities
1. Does your site complete a survey for any of the following types of facilities:
a. Physician/Outpatient provider: ____yes ____no
i. If yes, the last survey was completed in: _________________
b. LTCF: ____yes ____no
i. If yes, the last survey was completed in: __________________________________
c. LTACH: ____yes ____no
i. If yes, the last survey was completed in: _________________
d. Dialysis center: ____yes ____no
i. If yes, the last survey was completed in: _________________
e. Hospital laboratory: ____yes ____no
i. If yes, the last survey was completed in: _________________
2. What is the IRB determination for MuGSI at your site? Please describe: _____________________________

Public reporting burden of this collection of information is estimated to average 15 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 dis plays a current 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 Rd NE, MS D-74, Atlanta, Georgia 30329; ATTN: PRA (xxxx-xxxx)