Case Report Form (CRF) - B. multivorans

Form Approved
OMB Control No.: 0920-XXXX
Expiration Date: XX/XX/XXXX

Burkholderia multivorans
Outbreak Investigation Case Report Form

Jurisdiction:
Local Epi ID:
Local Lab ID:
Facility ID:

Burden statement:
Public reporting burden of this collection of information is estimated to average 3 hours 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 H21-8, Atlanta, Georgia 30333; ATTN:
PRA 0920-XXXX

Local Epi ID _________________________

/

Local Lab ID _______________________________

Form Approved
OMB Control No.: 0920-XXXX
Expiration Date: XX/XX/XXXX

Burkholderia multivorans
Case Report Form
Record ID: _______________________________
(NOTE: This is autogenerated by REDCap and does not need to be completed on paper forms)
=====================================================================================
SECTION 1. ID NUMBERS
CDC will assign the CDC Epi ID and CDC Lab ID numbers. The Local Epi ID, Local Lab ID, and Facility ID
are numbers that are assigned and entered by the health department. The Local Epi ID will correspond
to the patient and the Local Lab ID number will correspond to the patient’s isolate. The Facility ID will
correspond to the healthcare facility associated with the patient’s index specimen and where the
patient’s medical record information will be abstracted from. For Local Epi, Local Lab, and Facility IDs,
use the same numbers you have created for your records or sent in previous communications to CDC.
State: _______________________________
Local Epi ID: _______________________________
(Please ensure this ID matches any previously communicated information on this patient)
Local Lab ID: _______________________________
(Please ensure this ID matches any previously communicated information on this patient)
Facility ID: _______________________________
(Healthcare facility associated with the patient’s index specimen)
(Please ensure this ID matches any previously communicated information on this patient)
CDC Epi ID: _______________________________
CDC Lab ID: _______________________________
Date chart abstraction was completed: ____ /____ /______
MM DD YYYY
Abstractor’s initials: _______________________________
=====================================================================================
SECTION 2. PATIENT DEMOGRAPHICS
Patient age: ___________
(Patient age at date of index specimen collection [first specimen where B. multivorans
was isolated])

Local Epi ID _________________________

/

Local Lab ID _______________________________

Form Approved
OMB Control No.: 0920-XXXX
Expiration Date: XX/XX/XXXX
Patient age:
Years
Months (select only if patient is less than 1 year of age)
only if patient is less than 1 month of age)
Patient sex (biological sex assigned at birth):

Male

Female

Days (select

Unknown/Not reported

Patient race and/or ethnicity (select all that apply):
□ American Indian or Alaska Native
□ Asian
□ Black or African American
□ Hispanic or Latino
□ Middle Eastern or North African
□ Native Hawaiian or Other Pacific Islander
□ White
□ Other, specify: _______________________________
=====================================================================================
SECTION 3. MICROBIOLOGY
Index specimen is the first specimen where B. multivorans was isolated. Count specimens from the
same source collected on the same day as a single specimen. Count specimens separately if collected
on different days or from different specimen sources.
Date of index specimen collection: ____ /____ /______
MM DD YYYY
Index specimen source (culture 1):
o Blood
o Cerebrospinal fluid
o Cutaneous/skin (e.g., abscess, bullae, purulent cellulitis, vesicles, pustules), specify:
_______________________________
o Intra-abdominal fluid/aspirate (e.g., ascitic fluid, peritoneal fluid, biliary fluid, abscess aspirate),
specify: _______________________________
o Joint/synovial fluid
o Respiratory (e.g., sputum, bronchial brush/wash/lavage, endotracheal aspirate, pleural fluid,
nasopharyngeal), specify: _______________________________
o Tissue, specify: _______________________________
o Urine (e.g., midstream, suprapubic aspiration, indwelling catheter urine, nephrostomy tube),
specify: _______________________________
o Wound, specify: _______________________________
o Other, specify: _______________________________
What was the type of unit/location the patient was on at the time of index specimen collection (culture
1)?
o Bone marrow transplant unit
o Burn unit
o Emergency department
o Interventional radiology room
o Labor/delivery
Local Epi ID _________________________

/

Local Lab ID _______________________________

Form Approved
OMB Control No.: 0920-XXXX
Expiration Date: XX/XX/XXXX
o
o
o
o
o
o
o
o
o
o
o
o

Medical intensive care unit (ICU)
Medical/surgical unit, specify: _______________________________
Not admitted/outpatient clinic
Observation unit
Oncology unit
Operating room
Other ICU, specify: _______________________________
Solid organ transplant unit
Step down unit
Surgical/trauma ICU
Urgent care
Other, specify: _______________________________

Were other organisms isolated from the index specimen source (culture 1)?

Yes

No

If yes, which other organisms were isolated from the index specimen source (culture 1)?
_______________________________
Was B. multivorans isolated from a different specimen source collected on the same day as the index
specimen source (culture 1)?
Yes
No
If yes, from what other specimen source(s) (Select all that apply)
□ Blood
□ Cerebrospinal fluid
□ Cutaneous/skin (e.g., abscess, bullae, purulent cellulitis, vesicles, pustules), specify:
_______________________________
□ Intra-abdominal fluid/aspirate (e.g., ascitic fluid, peritoneal fluid, biliary fluid, abscess
aspirate), specify: _______________________________
□ Joint/synovial fluid
□ Respiratory (e.g., sputum, bronchial brush/wash/lavage, endotracheal aspirate, pleural
fluid, nasopharyngeal), specify: _______________________________
□ Tissue, specify: _______________________________
□ Urine (e.g., midstream, suprapubic aspiration, indwelling catheter urine, nephrostomy
tube), specify: _______________________________
□ Wound, specify: _______________________________
□ Other, specify: _______________________________
Was B. multivorans isolated from additional specimen sources collected after the date that the index
specimen source (culture 1) was obtained?
Yes
No
If yes, from what specimen source(s)? (Select all that apply and list the date(s) of collection)
□ Blood, list the date(s) of specimen collection (mm-dd-yyyy): _________________
□ Cerebrospinal fluid, list the date(s) of specimen collection (mm-dd-yyyy):
_________________

Local Epi ID _________________________

/

Local Lab ID _______________________________

Form Approved
OMB Control No.: 0920-XXXX
Expiration Date: XX/XX/XXXX
□

□

□
□

□
□

□
□

Cutaneous/skin (e.g., abscess, bullae, purulent cellulitis, vesicles, pustules), specify site
and list the date(s) of specimen collection (mm-dd-yyyy) next to each site:
_________________
Intra-abdominal fluid/aspirate (e.g., ascitic fluid, peritoneal fluid, biliary fluid, abscess
aspirate), specify site and list the date(s) of specimen collection (mm-dd-yyyy) next to
each site: _________________
Joint/synovial fluid, specify site and list the date(s) of specimen collection (mm-dd-yyyy)
next to each site: _________________
Respiratory (e.g., sputum, bronchial brush/wash/lavage, endotracheal aspirate, pleural
fluid, nasopharyngeal), specify site and list the date(s) of specimen collection (mm-ddyyyy) next to each site: _________________
Tissue, specify site and list the date(s) of specimen collection (mm-dd-yyyy) next to each
site: _________________
Urine (e.g., midstream, suprapubic aspiration, indwelling catheter urine, nephrostomy
tube), specify site and list the date(s) of specimen collection (mm-dd-yyyy) next to each
site: _________________
Wound, specify site and list the date(s) of specimen collection (mm-dd-yyyy) next to
each site: _________________
Other, specify site and list the date(s) of specimen collection (mm-dd-yyyy) next to each
site: _________________

=====================================================================================
SECTION 4. PAST MEDICAL HISTORY
The patient’s past medical history information may be obtained either from a “Problem List” section
of the medical record (if available) and/or the past medical history section in the hospital admission
note corresponding to admission where the index specimen was collected.
Did the patient have any underlying medical conditions present at the time of index specimen
collection?
Yes
No
If yes, which of the following underlying conditions? (Select all that apply)
□ Cancer (any malignancy, including lymphoma, leukemia, and metastatic skin cancer)
If yes, what type of cancer? _______________________________
Receiving chemotherapy or radiation therapy at time of index culture
collection?
Yes
No
Unknown
□ Cirrhosis
□ Cystic fibrosis
□ Diabetes mellitus
□ End-stage renal disease/dialysis-dependent
If yes, type of dialysis
o Hemodialysis
o Peritoneal dialysis
□ HIV with prior history of AIDS or AIDS-defining illness?
Yes
No
Unknown
Examples: candidiasis, cryptococcosis, coccidioidomycosis, histoplasmosis,
Kaposi sarcoma, Burkitt lymphoma, cytomegalovirus retinitis with loss of vision,
wasting syndrome, tuberculosis, disseminated or extrapulmonary infection due
to Mycobacterium sp., Pneumocystis jirovecii pneumonia, etc.
Local Epi ID _________________________

/

Local Lab ID _______________________________

Form Approved
OMB Control No.: 0920-XXXX
Expiration Date: XX/XX/XXXX
□

□

□

Other treatments that may result in moderate-to-severe immunosuppression, specify:
_______________________________
Examples: receipt of chimeric antigen receptor (CAR)-T-cell therapy, active
treatment with high-dose systemic corticosteroids (i.e., 20 or more mg of
prednisone or equivalent per day for 2 or more week), biologic agents that are
immunosuppressive or immunomodulatory, etc.
Transplant recipient
If yes, type of transplant (e.g., liver, stem cell, etc.): __________________
Receiving immunosuppressive therapy at the time of index specimen collection?
Yes
No
Unknown
Other, specify: _______________________________

=====================================================================================
SECTION 5. ACUTE CARE HOSPITAL ADMISSION
List all acute care hospital admissions in the 14 days prior to the date of index specimen collection.
When determining timeframes, please consider the date of index specimen collection as day 0. Please,
list admissions from most recent to oldest.
PLEASE, REFER TO THE SUPPLEMENTARY MATERIALS SECTION IN THIS CASE REPORT FORM IF YOU
NEED TO COMPLETE THIS SECTION FOR ADDITIONAL HOSPITAL ADMISSIONS.
How many admissions to an acute care hospital did the patient have in the 14 days prior to the date of
index specimen collection (day 0)? ______
Admission # ___
Facility ID: _______________________________
Facility street address: _______________________________
Facility city: _______________________________
Facility state (two letter code): __________
Facility ZIP code: __________
Admit date: ____ /____ /______
MM DD YYYY
Primary diagnosis at admission: _______________________________
Admitted/transferred from:
o Home/residence
o Residential care setting (e.g., assisted living facility, group home, intermediate care, etc.)
o Acute care hospital
o Critical access hospital
o Emergency department
o Long-term acute care hospital
o Skilled nursing facility
o Ventilator-capable skilled nursing facility
o Inpatient/resident rehabilitation facility
o Other, specify: _______________________________
What unit was the patient admitted to? _______________________________

Local Epi ID _________________________

/

Local Lab ID _______________________________

Form Approved
OMB Control No.: 0920-XXXX
Expiration Date: XX/XX/XXXX
During this hospital admission, did the patient move or change locations in the hospital in the 14
days prior to the date of index specimen collection (day 0)?
Yes
No
Unknown
If yes, list all locations, including locations where the patient spent less than 24 hours
(e.g., operating room, observation area, post-acute care unit, etc.), and the range of
dates that the patient spent at these locations (include locations on day 0 as well:
Unit: _________________
From: ___ / ___ / _____
To: ___ / ___ / _____
MM DD YYYY
MM DD YYYY
Unit: _________________
From: ___ / ___ / _____
To: ___ / ___ / _____
MM DD YYYY
MM DD YYYY
Unit: _________________
From: ___ / ___ / _____
To: ___ / ___ / _____
MM DD YYYY
MM DD YYYY
Unit: _________________
From: ___ / ___ / _____
To: ___ / ___ / _____
MM DD YYYY
MM DD YYYY
Unit: _________________
From: ___ / ___ / _____
To: ___ / ___ / _____
MM DD YYYY
MM DD YYYY
Unit: _________________
From: ___ / ___ / _____
To: ___ / ___ / _____
MM DD YYYY
MM DD YYYY
Unit: _________________
From: ___ / ___ / _____
To: ___ / ___ / _____
MM DD YYYY
MM DD YYYY
Unit: _________________
From: ___ / ___ / _____
To: ___ / ___ / _____
MM DD YYYY
MM DD YYYY
Unit: _________________
From: ___ / ___ / _____
To: ___ / ___ / _____
MM DD YYYY
MM DD YYYY
Unit: _________________
From: ___ / ___ / _____
To: ___ / ___ / _____
MM DD YYYY
MM DD YYYY
Unit: _________________
From: ___ / ___ / _____
To: ___ / ___ / _____
MM DD YYYY
MM DD YYYY
Unit: _________________
From: ___ / ___ / _____
To: ___ / ___ / _____
MM DD YYYY
MM DD YYYY
Unit: _________________
From: ___ / ___ / _____
To: ___ / ___ / _____
MM DD YYYY
MM DD YYYY
Unit: _________________
From: ___ / ___ / _____
To: ___ / ___ / _____
MM DD YYYY
MM DD YYYY
Unit: _________________
From: ___ / ___ / _____
To: ___ / ___ / _____
MM DD YYYY
MM DD YYYY
Unit: _________________
From: ___ / ___ / _____
To: ___ / ___ / _____
MM DD YYYY
MM DD YYYY
Unit: _________________
From: ___ / ___ / _____
To: ___ / ___ / _____
MM DD YYYY
MM DD YYYY
Unit: _________________
From: ___ / ___ / _____
To: ___ / ___ / _____
MM DD YYYY
MM DD YYYY
Unit: _________________
From: ___ / ___ / _____
To: ___ / ___ / _____
MM DD YYYY
MM DD YYYY
Unit: _________________
From: ___ / ___ / _____
To: ___ / ___ / _____
MM DD YYYY
MM DD YYYY
=====================================================================================
Local Epi ID _________________________

/

Local Lab ID _______________________________

Form Approved
OMB Control No.: 0920-XXXX
Expiration Date: XX/XX/XXXX

SECTION 6. HISTORY OF MEDICAL DEVICES, LINES, AND PROCEDURES OR SURGERIES
Which of the following invasive medical devices or lines did the patient have in the 14 days prior to the
date of index specimen collection (day 0) (including day 0)? (Select all that apply)
□ Central venous catheter (e.g., peripherally inserted central catheter [PICC], tunneled catheter,
implanted port, etc.)
□ Arterial line
□ BiPAP/CPAP (non-invasive ventilation)
□ Endotracheal tube (intubation)
□ Tracheostomy tube
□ Gastrostomy feeding tube (e.g., PEG tube, J tube, G tube)
□ Biliary drainage catheter
□ Invasive or indwelling urinary catheter (e.g., foley catheter)
□ Suprapubic urinary catheter
□ Nephrostomy tube
□ Other, specify: _______________________________
Which of the following procedures or surgeries did the patient receive in the 14 days prior to the date of
index specimen collection (day 0) (including day 0) (Select all that apply)
□ Bronchoscopy
□ Endoscopy
□ Colonoscopy
□ Hemodialysis
□ Peritoneal dialysis
□ Invasive urological procedure (e.g., cystoscopy), specify: _______________________________
□ Paracentesis
□ Endoscopic retrograde cholangiopancreatography (ERCP)
□ Surgical procedure, specify: _______________________________
□ Other, specify: _______________________________
Did the patient receive wound care in the 14 days prior to the date of index specimen collection (day 0)
(including day 0)?
Yes
No
Did the patient receive occupational therapy evaluations (e.g., swallow and speech evaluations) in the
14 days prior to the date of index specimen collection (day 0) (including day 0)?
Yes
No
If yes, please describe: _______________________________
Did the patient receive physical therapy evaluations in the 14 days prior to the date of index specimen
collection (day 0) (including day 0)?
Yes
No
If yes, please describe: _______________________________
=====================================================================================
SECTION 7. PATIENT OUTCOMES
Was the patient treated for the B. multivorans?
Local Epi ID _________________________

Yes
/

No

Local Lab ID _______________________________

Form Approved
OMB Control No.: 0920-XXXX
Expiration Date: XX/XX/XXXX

If yes, what was the primary infection type? (Select only one)
o Urinary tract infection
o Pneumonia
o Bloodstream infection (with no source of infection documented)
o Skin/wound/tissue infection
o Other, specify: ______________________________
Any additional clinical details, if relevant: ___________________________
Patient outcome at time of medical record review?
Death
Discharged
If deceased, was B. multivorans considered the primary cause of death?
Yes
No
Unknown

Local Epi ID _________________________

/

Still admitted

Local Lab ID _______________________________

Form Approved
OMB Control No.: 0920-XXXX
Expiration Date: XX/XX/XXXX

Supplementary Materials for
Burkholderia multivorans
Case Report Form

Local Epi ID _________________________

/

Local Lab ID _______________________________

Form Approved
OMB Control No.: 0920-XXXX
Expiration Date: XX/XX/XXXX
Additional forms for SECTION 5. ACUTE CARE HOSPITAL ADMISSION
List all acute care hospital admissions in the 14 days prior to the date of index specimen collection.
When determining timeframes, please consider the date of index specimen collection as day 0. Please,
list admissions from most recent to oldest.
Admission # ___
Facility ID: _______________________________
Facility street address: _______________________________
Facility city: _______________________________
Facility state (two letter code): __________
Facility ZIP code: __________
Admit date: ____ /____ /______
MM DD YYYY
Primary diagnosis at admission: _______________________________
Admitted/transferred from:
o Home/residence
o Residential care setting (e.g., assisted living facility, group home, intermediate care, etc.)
o Acute care hospital
o Critical access hospital
o Emergency department
o Long-term acute care hospital
o Skilled nursing facility
o Ventilator-capable skilled nursing facility
o Inpatient/resident rehabilitation facility
o Other, specify: _______________________________
What unit was the patient admitted to? _______________________________
During this hospital admission, did the patient move or change locations in the hospital in the 14
days prior to the date of index specimen collection (day 0)?
Yes
No
Unknown
If yes, list all locations, including locations where the patient spent less than 24 hours
(e.g., operating room, observation area, post-acute care unit, etc.), and the range of
dates that the patient spent at these locations (please, include locations on day 0 as
well:
Unit: _________________
From: ___ / ___ / _____
To: ___ / ___ / _____
MM DD YYYY
MM DD YYYY
Unit: _________________
From: ___ / ___ / _____
To: ___ / ___ / _____
MM DD YYYY
MM DD YYYY
Unit: _________________
From: ___ / ___ / _____
To: ___ / ___ / _____
MM DD YYYY
MM DD YYYY
Unit: _________________
From: ___ / ___ / _____
To: ___ / ___ / _____
MM DD YYYY
MM DD YYYY
Unit: _________________
From: ___ / ___ / _____
To: ___ / ___ / _____
MM DD YYYY
MM DD YYYY
Unit: _________________
From: ___ / ___ / _____
To: ___ / ___ / _____
MM DD YYYY
MM DD YYYY
Unit: _________________
From: ___ / ___ / _____
To: ___ / ___ / _____
Local Epi ID _________________________

/

Local Lab ID _______________________________

Form Approved
OMB Control No.: 0920-XXXX
Expiration Date: XX/XX/XXXX

Unit: _________________
Unit: _________________
Unit: _________________
Unit: _________________
Unit: _________________
Unit: _________________
Unit: _________________
Unit: _________________
Unit: _________________
Unit: _________________
Unit: _________________
Unit: _________________
Unit: _________________

Local Epi ID _________________________

MM DD YYYY
From: ___ / ___ / _____
MM DD YYYY
From: ___ / ___ / _____
MM DD YYYY
From: ___ / ___ / _____
MM DD YYYY
From: ___ / ___ / _____
MM DD YYYY
From: ___ / ___ / _____
MM DD YYYY
From: ___ / ___ / _____
MM DD YYYY
From: ___ / ___ / _____
MM DD YYYY
From: ___ / ___ / _____
MM DD YYYY
From: ___ / ___ / _____
MM DD YYYY
From: ___ / ___ / _____
MM DD YYYY
From: ___ / ___ / _____
MM DD YYYY
From: ___ / ___ / _____
MM DD YYYY
From: ___ / ___ / _____
MM DD YYYY

/

MM DD YYYY
To: ___ / ___ / _____
MM DD YYYY
To: ___ / ___ / _____
MM DD YYYY
To: ___ / ___ / _____
MM DD YYYY
To: ___ / ___ / _____
MM DD YYYY
To: ___ / ___ / _____
MM DD YYYY
To: ___ / ___ / _____
MM DD YYYY
To: ___ / ___ / _____
MM DD YYYY
To: ___ / ___ / _____
MM DD YYYY
To: ___ / ___ / _____
MM DD YYYY
To: ___ / ___ / _____
MM DD YYYY
To: ___ / ___ / _____
MM DD YYYY
To: ___ / ___ / _____
MM DD YYYY
To: ___ / ___ / _____
MM DD YYYY

Local Lab ID _______________________________

Form Approved
OMB Control No.: 0920-XXXX
Expiration Date: XX/XX/XXXX

Burkholderia multivorans
Facility-Level Form
Record ID: _______________________________
(NOTE: This is autogenerated by REDCap and does not need to be completed on paper forms)
=====================================================================================
SECTION 1. ID NUMBERS
This section can be completed by the health department staff prior to the interview. CDC will assign
the CDC Epi ID numbers. The Local Epi ID and the Facility ID numbers are assigned and entered by the
health department. The Local Epi ID will correspond to the patient. For Local Epi and Facility IDs, use
the same numbers you have created for your records or sent in previous communications to CDC.
•

If the patient was admitted to more than one hospital for more than 48 hours in the 14 days
prior to the date of index specimen collection: PLEASE, COMPLETE A NEW FACILITY-LEVEL
FORM FOR EACH ACUTE CARE HOSPITAL (FACILITY ID) ASSOCIATED WITH THIS CASE-PATIENT.

•

If the patient had multiple admissions to the same acute care hospital in the 14 days prior to
the date of index specimen collection: Complete the facility-level form only once but reference
the list of locations/units where the patient was placed during all admissions to this hospital
when completing the questions on ice machines.

•
State: _______________________________

Facility ID: _______________________________
(Please ensure this ID matches any previously communicated information on this patient)
Is there more than one case-patient associated with this facility?
Yes
No
If yes, how many case-patients are associated with this facility? ___________
Local Epi ID: _______________________________
(Please ensure this ID matches any previously communicated information on this patient)

CDC Epi ID: _______________________________
=====================================================================================
SECTION 2. USE OF NONSTERILE ICE OR WATER FROM ICE MACHINES FOR CLINICAL CARE ACTIVITIES
How was the information obtained to complete this form? (Select all that apply)
□ Onsite visit with direct observation
Local Epi ID _________________________

/

Local Lab ID _______________________________

Form Approved
OMB Control No.: 0920-XXXX
Expiration Date: XX/XX/XXXX
□
□
□
□

Onsite visit without direct observation
Remote phone consultation
Email correspondence
Other, please specify: _________________________

For what patient care activities is ice from ice machines used at the hospital? (Select all that apply)
□ Consumption/hydration
□ Bathing
□ Reducing fever
□ Reducing pain
□ Reducing inflammation
□ Occupational therapy evaluations (e.g., swallow and speech evaluations), specify:
_______________________________
□ Physical therapy evaluations, specify: _______________________________
□ Other, specify: _______________________________
□ None
How are ice packs or bags cleaned and disinfected after using on a patient? Describe.
_______________________________
For what patient care activities is water from ice machines used at the hospital? (Select all that apply)
□ Consumption/hydration
□ Bathing
□ Reducing fever
□ Reducing pain
□ Reducing inflammation
□ Occupational therapy evaluations (e.g., swallow and speech evaluations), specify:
_______________________________
□ Physical therapy evaluations, specify: _______________________________
□ Other, specify: _______________________________
□ None
Is ice or water from ice machines used to cool medications or products prior to patient administration
(e.g., albuterol nebulizer solution, etc.)?
Yes
No
Unknown
If yes, describe types of medications or products. _______________________________
If yes, where is the ice or water obtained from (e.g., unit/location of ice machine)?
_______________________________
Is ice or water from ice machines used to actively cool endoscopes (e.g., bronchoscopes) during a
procedure?
Yes
No
Unknown
If yes, where is the ice or water obtained from (e.g., unit/location of ice machine)?
_______________________________
Is ice or water from ice machines used during other procedures or surgeries?
Yes
No
Unknown
If yes, describe types of procedures or surgeries. _______________________________
Local Epi ID _________________________

/

Local Lab ID _______________________________

Form Approved
OMB Control No.: 0920-XXXX
Expiration Date: XX/XX/XXXX
If yes, describe how ice or water is used during each of these procedures or surgeries.
_______________________________
If yes, where is the ice or water obtained from (e.g., unit/location of ice machine)?
_______________________________

Local Epi ID _________________________

/

Local Lab ID _______________________________

Form Approved
OMB Control No.: 0920-XXXX
Expiration Date: XX/XX/XXXX
SECTION 3. ICE MACHINES AND USE OF NONSTERILE ICE/WATER FROM ICE MACHINES
Facility ID: _______________________________
(Please ensure this ID matches any previously communicated information on this patient)
Describe the frequency of cleaning/descaling and sanitizing the following of all ice machines of the same brand and model at the hospital.
Please, complete a new table for each different brand/model of ice machine located in a unit/area where the patient might have spent time
during their hospital admission.
Brand
Model
Component Frequency
Drain line
□ Weekly □ Bi-weekly □ Monthly □ Bi-monthly □ Quarterly □ Bi-annually □ Annually □ Other,
specify:
Drain
□ Weekly □ Bi-weekly □ Monthly □ Bi-monthly □ Quarterly □ Bi-annually □ Annually □ Other,
pain/drip
specify:
pan
Condenser
□ Weekly □ Bi-weekly □ Monthly □ Bi-monthly □ Quarterly □ Bi-annually □ Annually □ Other,
specify:
Dispenser
□ Weekly □ Bi-weekly □ Monthly □ Bi-monthly □ Quarterly □ Bi-annually □ Annually □ Other,
and
specify:
components
Ice machine □ Weekly □ Bi-weekly □ Monthly □ Bi-monthly □ Quarterly □ Bi-annually □ Annually □ Other,
specify:
Transport
□ Weekly □ Bi-weekly □ Monthly □ Bi-monthly □ Quarterly □ Bi-annually □ Annually □ Other,
tube
specify:
Ice storage
□ Weekly □ Bi-weekly □ Monthly □ Bi-monthly □ Quarterly □ Bi-annually □ Annually □ Other,
area/bin
specify:
Pressurized □ Weekly □ Bi-weekly □ Monthly □ Bi-monthly □ Quarterly □ Bi-annually □ Annually □ Other,
water line
specify:
sanitizing

Local Epi ID _________________________

/

Local Lab ID _______________________________

Form Approved
OMB Control No.: 0920-XXXX
Expiration Date: XX/XX/XXXX
Are ice machines part of the facility’s water management plan?
o Yes, ice machines are part of the facility’s water management plan and testing of the ice
or water from ice machines is included in the plan.
If yes, what testing or monitoring of ice machines is part of the water management
plan? (Select all that apply)
□ Legionella sp. testing
□ Coliform testing (e.g., total coliform, fecal coliform, Escherichia coli, etc.)
□ Heterotrophic plate count (HPC)
□ Other, specify: _______________________________
o Yes, ice machines are part of the facility’s water management plan, but the plan does
not include testing of the ice or water from ice machines.
o No, ice machines are not part of the facility’s water management plan.
o No, the facility does not have a water management plan.
o Unknown
Reference the list of locations/units where the patient was placed during the hospital admission (see
SECTION 5. ACUTE CARE HOSPITAL ADMISSION from the medical record abstraction form).
Facility ID: _______________________________
(Please ensure this ID matches any previously communicated information on this patient)
Did the patient spend time at a unit/location with an ice machine during the hospital admission?
Yes
No
Unknown
If no, STOP HERE
If yes, continue with the following questions.
Complete the following questions for all ice machines located in units/locations where the patient
was placed during admission to this acute care hospital. If the patient had multiple admissions to the
same acute care hospital and spent time in the same units/locations in the 14 days prior to index
specimen collection, list those units/locations only once.
PLEASE, REFER TO THE SUPPLEMENTARY MATERIALS SECTION IN THIS FACILITY-LEVEL FORM IF YOU
NEED TO COMPLETE THIS SECTION FOR ADMISSIONS TO MORE THAN ONE UNIT/LOCATION AND FOR
A DIFFERENT FACILITY IDs.
Facility ID: _______________________________
(Please ensure this ID matches any previously communicated information on this patient)
Unit/location: _____________
How many ice machines are located in this unit/location? ________________
Please, complete the following information for all ice machines in this unit/location. Use a new form for
each ice machine.
Brand of ice machine: _______________________________
Local Epi ID _________________________

/

Local Lab ID _______________________________

Form Approved
OMB Control No.: 0920-XXXX
Expiration Date: XX/XX/XXXX

Model of ice machine: _______________________________
Serial number of ice machine: _______________________________
Purchase date of ice machine: ___ / _____
MM YYYY
Date when ice machine was put into use: ___ / _____
MM YYYYY
Was the ice machine connected to the facility’s water supply and checked for leaks during installation?
Yes
No
Unknown
If yes, unit/location of the hospital where it was connected and checked for leaks: ___________
Was the ice machine cleaned/descaled and sanitized during installation and prior to putting into use?
Yes
No
Unknown
Date of last periodic cleaning/descaling and sanitizing prior to the date of index specimen collection for
the first case-patient identified at this hospital: ___ / ___ /_____
MM DD YYYY
Please, list the following information for all cleaning/descaling products used in this ice machine:
Brand of cleaning/descaling product #1: _______________________________
Name of cleaning/descaling product #1: _______________________________
Lot number of cleaning/descaling product #1 used during the routine cleaning/descaling closest
to the date of index specimen collection for the first case-patient identified at this hospital (if
available): _______________________________
Does this product need to be mixed with water prior to use?
Yes
No
Unknown
If yes, is tap water used?
Yes
No
Unknown
If yes, where is this tap water obtained from? ___________________________
If yes, is hot tap water used (100°F or 38°C)?
Yes
No
Unknown
Is another cleaning/descaling product used in this ice machine?
Yes
No
Brand of cleaning/descaling product #2: _______________________________
Name of cleaning/descaling product #2: _______________________________
Lot number of cleaning/descaling product #2 used during the routine cleaning/descaling closest
to the date of index specimen collection for the first case-patient identified at this hospital (if
available): _______________________________
Does this product need to be mixed with water prior to use?
Yes
No
Unknown
If yes, is tap water used?
Yes
No
Unknown
If yes, where is this tap water obtained from? ___________________________
If yes, is hot tap water used (100°F or 38°C)?
Yes
No
Unknown

Local Epi ID _________________________

/

Local Lab ID _______________________________

Form Approved
OMB Control No.: 0920-XXXX
Expiration Date: XX/XX/XXXX
Brand of sanitizing product #1: _______________________________
Name of sanitizing product #1: _______________________________
Lot number of sanitizing product #1 used during the routine sanitizing closest to the date of
index specimen collection for the first case-patient identified at this hospital (if available):
_______________________________
Does this product need to be mixed with water prior to use?
Yes
No
Unknown
If yes, is tap water used?
Yes
No
Unknown
If yes, where is this tap water obtained from? ___________________________
If yes, is hot tap water used (100°F or 38°C)?
Yes
No
Unknown
Is another sanitizing product used in this ice machine?
Yes
No
Brand of sanitizing product #2: _______________________________
Name of sanitizing product #2: _______________________________
Lot number of sanitizing product #2 used during the routine sanitizing closest to the date of
index specimen collection for the first case-patient identified at this hospital (if available):
_______________________________
Does this product need to be mixed with water prior to use?
Yes
No
Unknown
If yes, is tap water used?
Yes
No
Unknown
If yes, where is this tap water obtained from? ___________________________
If yes, is hot tap water used (100°F or 38°C)?
Yes
No
Unknown
Is there a carbon filter attached to the water line that connects to this ice machine?
Yes
No
Unknown
If yes, how frequent is this filter changed? _______________________________
Date when filter was last changed prior to the date of index specimen collection for the first
case-patient identified at this hospital: ___ / ___ / ___
MM DD YYYY
Brand of carbon filter: _______________________________
Lot number of carbon filter installed at the time of index specimen collection for the first casepatient identified at this hospital: _______________
Is there a non-carbon filter (e.g., ultrafiltration filter) attached to the water line that connects to this ice
machine?
Yes
No
Unknown
If yes, how frequent is this filter changed? _______________________________
Date when filter was last changed prior to the date of index specimen collection for the first
case-patient identified at this hospital: ___ / ___ / ___
MM DD YYYY
Brand of non-carbon filter: _______________________________
Type of non-carbon filter: _______________________________
Lot number of non-carbon filter installed at the time of index specimen collection for the first
case-patient identified at this hospital: ______________
Is this filter located after the carbon filter (i.e., closer to the water inlet of the ice machine)?
Yes
No
Unknown

Local Epi ID _________________________

/

Local Lab ID _______________________________

Form Approved
OMB Control No.: 0920-XXXX
Expiration Date: XX/XX/XXXX

Supplementary Materials for
Burkholderia multivorans
Facility-Level Form

Local Epi ID _________________________

/

Local Lab ID _______________________________

Form Approved
OMB Control No.: 0920-XXXX
Expiration Date: XX/XX/XXXX

Complete the following questions for all ice machines located in units/locations where the patient
was placed during the hospital admission.
Facility ID: _______________________________
(Please ensure this ID matches any previously communicated information on this patient)
Unit/location: _____________
How many ice machines are located in this unit/location? ________________
Please, complete the following information for all ice machines in this unit/location. Use a new form for
each ice machine.
Brand of ice machine: _______________________________
Model of ice machine: _______________________________
Serial number of ice machine: _______________________________
Purchase date of ice machine: ___ / _____
MM YYYY
Date when ice machine was put into use: ___ / _____
MM YYYYY
Was the ice machine connected to the facility’s water supply and checked for leaks during installation?
Yes
No
Unknown
If yes, unit/location of the hospital where it was connected and checked for leaks: ___________
Was the ice machine cleaned/descaled and sanitized during installation and prior to putting into use?
Yes
No
Unknown
Date of last periodic cleaning/descaling and sanitizing prior to the date of index specimen collection for
the first case-patient identified at this hospital: ___ / ___ /_____
MM DD YYYY
Please, list the following information for all cleaning/descaling products used in this ice machine:
Brand of cleaning/descaling product #1: _______________________________
Name of cleaning/descaling product #1: _______________________________
Lot number of cleaning/descaling product #1 used during the routine cleaning/descaling closest
to the date of index specimen collection for the first case-patient identified at this hospital (if
available): _______________________________
Does this product need to be mixed with water prior to use?
Yes
No
Unknown
If yes, is tap water used?
Yes
No
Unknown
Local Epi ID _________________________

/

Local Lab ID _______________________________

Form Approved
OMB Control No.: 0920-XXXX
Expiration Date: XX/XX/XXXX
If yes, where is this tap water obtained from? ___________________________
If yes, is hot tap water used (100°F or 38°C)?
Yes
No
Unknown
Is another cleaning/descaling product used in this ice machine?
Yes
No
Brand of cleaning/descaling product #2: _______________________________
Name of cleaning/descaling product #2: _______________________________
Lot number of cleaning/descaling product #2 used during the routine cleaning/descaling closest
to the date of index specimen collection for the first case-patient identified at this hospital (if
available): _______________________________
Does this product need to be mixed with water prior to use?
Yes
No
Unknown
If yes, is tap water used?
Yes
No
Unknown
If yes, where is this tap water obtained from? ___________________________
If yes, is hot tap water used (100°F or 38°C)?
Yes
No
Unknown
Brand of sanitizing product #1: _______________________________
Name of sanitizing product #1: _______________________________
Lot number of sanitizing product #1 used during the routine sanitizing closest to the date of
index specimen collection for the first case-patient identified at this hospital (if available):
_______________________________
Does this product need to be mixed with water prior to use?
Yes
No
Unknown
If yes, is tap water used?
Yes
No
Unknown
If yes, where is this tap water obtained from? ___________________________
If yes, is hot tap water used (100°F or 38°C)?
Yes
No
Unknown
Is another sanitizing product used in this ice machine?
Yes
No
Brand of sanitizing product #2: _______________________________
Name of sanitizing product #2: _______________________________
Lot number of sanitizing product #2 used during the routine sanitizing closest to the date of
index specimen collection for the first case-patient identified at this hospital (if available):
_______________________________
Does this product need to be mixed with water prior to use?
Yes
No
Unknown
If yes, is tap water used?
Yes
No
Unknown
If yes, where is this tap water obtained from? ___________________________
If yes, is hot tap water used (100°F or 38°C)?
Yes
No
Unknown
Is there a carbon filter attached to the water line that connects to this ice machine?
Yes
No
Unknown
If yes, how frequent is this filter changed? _______________________________
Date when filter was last changed prior to the date of index specimen collection for the first
case-patient identified at this hospital: ___ / ___ / ___
MM DD YYYY
Brand of carbon filter: _______________________________
Lot number of carbon filter installed at the time of index specimen collection for the first casepatient identified at this hospital: _______________
Local Epi ID _________________________

/

Local Lab ID _______________________________

Form Approved
OMB Control No.: 0920-XXXX
Expiration Date: XX/XX/XXXX
Is there a non-carbon filter (e.g., ultrafiltration filter) attached to the water line that connects to this ice
machine?
Yes
No
Unknown
If yes, how frequent is this filter changed? _______________________________
Date when filter was last changed prior to the date of index specimen collection for the first
case-patient identified at this hospital: ___ / ___ / ___
MM DD YYYY
Brand of non-carbon filter: _______________________________
Type of non-carbon filter: _______________________________
Lot number of non-carbon filter installed at the time of index specimen collection for the first
case-patient identified at this hospital: ______________
Is this filter located after the carbon filter (i.e., closer to the water inlet of the ice machine)?
Yes
No
Unknown

Local Epi ID _________________________

/

Local Lab ID _______________________________

Form Approved
OMB Control No.: 0920-XXXX
Expiration Date: XX/XX/XXXX

Local Epi ID _________________________

/

Local Lab ID _______________________________