Form HAIC.400.9 HAIC Surveillance Officer’s Survey

Form Approved
OMB No. 0092-0978

Surveillance Officer’s Survey
CDC’s Emerging Infections Program
Clostridioides difficile Infection (CDI) Surveillance

Lab participation, practices, and auditing
1. How does your site verify that laboratories are sending you complete lists of C. diff cases?
How often does your site do this verification? If your approach is different for different types
of labs, please note what those differences are.
2. In 2023, did any laboratories drop out of participation?
o Yes
o No
If yes:
How many?
Why did these labs drop out of participation?
3. In 2023, did you identify any additional laboratories inside or outside of your catchment area
which identify C.diff assays from persons who are residents of your catchment area?
o Yes
o No
If yes:
How many of these laboratories were inside the catchment area?
How many of these laboratories were outside the catchment area?
Approximately how many cases does this (or these) lab(s) identify per quarter (if more than one
lab please provide the range)?
How many were found using the LTCF Survey?
How many were found because the lab submitted a case to you as part of mandated case
reporting?
How many were found in some other way (please specify)?

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
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
30329; ATTN: PRA (0920-0978).

Form Approved
OMB No. 0092-0978

4. Are you seeing a decline in numbers of specimens saved from any of your laboratories?
o Yes
o No
If yes, why?
5. Did any of your laboratories stop saving specimens for surveillance?
o Yes
o No
If yes, why?
6. Please describe your procedure for gathering and transporting frozen stool specimens to Hines
(if applicable). Does someone in your site decant stool into the shipping containers, or do you
receive these directly from the facility? How long are you storing the specimens before
shipment and under what storage conditions (e.g., temperature)? If there are differences for
each lab, please note what those differences are.

7. Please describe your procedure for gathering and transporting stool swabs to Hines (if
applicable). Does someone in your site do the swabbing, or do you receive swabs from each
facility? If you do not collect swabs right away, how long do you usually store the stool
specimens before swabbing and under what storage conditions (e.g., temperature)? What type
of transport media do you use? Once you’ve sampled with swabs, on average how long are you
storing the swabs before shipment and under what storage conditions (e.g., temperature)? If
there are differences for each lab, please note what those differences are.

Data edits
8. How often do you conduct checks of your ICMS case report form data independent of the CDC
monthly edit checks (e.g. using a SAS program created by your site)? If you do this, please
describe the types of checks you do.
9. How often do you conduct checks of your ICDS case data (e.g. using a SAS program created by
your site)? If you do this, please describe the types of checks you do.

Provider Survey
10. Did your site complete a physician/outpatient provider survey in 2023?
o Yes
o No
If yes:
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
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
30329; ATTN: PRA (0920-0978).

Form Approved
OMB No. 0092-0978

Please describe your sampling scheme (if any).
How did you contact providers?
Where did you obtain the list of providers?
Did you learn any additional information that would be helpful for other sites?

Geocoding
11. What application do you use for geocoding (e.g. ArcGIS Pro, ArcMap, ArcGIS Online)?

12. Within this application, what geocoding tool do you use (e.g, StreetMap Premium, Spacialitics
Health Geocoder, ArcGIS World Geocoding service, locally-created address locator file)?

Facilities
13. For each facility that treated a case in 2023, please provide the following:
a. Facility ID or Provider ID as it appears on the CRF
b. Type of facility (i.e. hospital, outpatient, LTCF, LTACH, other). When possible, use the
CMS classification to determine type of facility
c. Either the state and county of the facility or an indication of if the facility is in catchment
or out of catchment

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
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
30329; ATTN: PRA (0920-0978).