Form CDC 57.128 Rev 7, CDC 57.128 Rev 7, Lab ID Event

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

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*required for saving **conditionally required

Facility ID:

Event #:

*Patient ID:

Social Security #:

Secondary ID:

Medicare #:

Patient Name, Last:

First:

Middle:

*Gender: M F

*Date of Birth:

Ethnicity (Specify):

Race (Specify):

Event Details

*Event Type: LabID

*Date Specimen Collected:

*Specific Organism Type: (Check one)

□ MDR-Acinetobacter

□ C. difficile

□ CephR-Klebsiella

□ CRE-E. coli

□ CRE-Enterobacter

□ CRE-Klebsiella

□ MRSA

□ MSSA

□ VRE

**Was the bacterial isolate tested for carbapenemase?

□ Yes

□ No

□ Unknown

If Yes, which test(s) were done? (check all that apply)

□ Polymerase chain reaction – Klebsiella pneumoniae carbapenemase (PCR-KPC)

□ Polymerase chain reaction – New Delhi metallo-β-lactamase (PCR-NDM)

□ Polymerase chain reaction – Imipenemase (PCR-IMP)

□ Polymerase chain reaction – Verona Integron-encoded metallo-β-lactamase (PCR-VIM)

□ Polymerase chain reaction – Oxacillinase-48 like (PCR-OXA-48-like)

□ Modified Hodge Test (MHT)

□ Carba NP (CNP)

□ Metallo-β-lactamase E-test (MBLe)

□ Metallo-β-lactamase screen (MBLs)

□ Other: (please specify): ______________________________

□ Unknown

**Did the isolate test positive for carbapenemase?

□ Yes

□ No

□ Unknown

If Yes, please identify which carbapenemase(s) were identified (check all that apply):

□ Klebsiella pneumoniae carbapenemase (KPC)

□ New Delhi metallo-β-lactamase (NDM)

□ Imipenemase (IMP)

□ Verona Integron-encoded metallo-β-lactamase (VIM)

□ Oxacillinase-48 like (OXA-48-like)

□ Nonspecific carbapenemase activity (e.g., MHT or Carba NP) (NS-Carba)

□ Nonspecific metallo-β-lactamase activity (e.g., MBL E-test or MBL screen) (NS-MBL)

□ Other: (please specify): ______________________________

□ Unknown

Assurance of Confidentiality: The voluntarily provided information obtained in this surveillance system that would permit identification of any individual or institution is collected with a guarantee that it will be held in strict confidence, will be used only for the purposes stated, and will not otherwise be disclosed or released without the consent of the individual, or the institution in accordance with Sections 304, 306 and 308(d) of the Public Health Service Act (42 USC 242b, 242k, and 242m(d)). Public reporting burden of this collection of information is estimated to average 20 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, Reports Clearance Officer, 1600 Clifton Rd., MS D-74, Atlanta, GA 30333, ATTN: PRA (0920-0666). CDC 57.128 Rev 7, v8.5

Laboratory-identified MDRO or CDI Event

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Event Details (continued)
*Outpatient:	□ Yes	□ No
*Specimen Body Site/System:					*Specimen Source:
*Date Admitted to Facility: __________				*Location:			*Date Admitted to Location: __________
**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):
□ Nursing Home/Skilled Nursing Facility
□ Personal residence/Residential care
□ Other Inpatient Healthcare Setting (i.e., acute care hospital, IRF, LTAC, etc.)
□ Unknown
*Has patient been discharged from your facility in the past 4 weeks?								□ Yes	□ No
If Yes, date of last discharge from your facility:_____________
*Has patient been discharged from another facility in the past 4 weeks?								□ Yes	□ No		□ Unknown
If Yes, from where (Check all that apply):
□ Nursing Home/Skilled Nursing Facility
□ Other Inpatient Healthcare Setting (i.e., acute care hospital, IRF, LTAC, etc.)
Custom Fields
Label					Label
_______________________			____/____/____			_______________________				____/____/____
_______________________			_____________			_______________________				_____________
_______________________			_____________			_______________________				_____________
_______________________			_____________			_______________________				_____________
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