Data Form 2 (screenshots)

Global Antimicrobial Resistance Laboratory & Response Network M&E
Page 1

2. Project Implementation and Referral
Network/Surveillance Activities
Record ID

Name of Recipient Organization:

__________________________________

__________________________________

FORM 2.) PROJECT IMPLEMENTATION AND REFERRAL NETWORK/ SURVEILLANCE ACTIVITIES
(PROJECT PARTNER/HEALTHCARE FACILITY/LABORATORY LEVEL) 
The following questions are related to project implementation with partners as well as
referral network and surveillance practices at EACH hospital, health care facility (HCF) and/or
laboratory that is participating in this organization's Global AR Lab & Response Network
project.  Please complete one form per partner, HCF/hospital, and/or laboratory.  Recipients
with projects in multiple countries or engaged with multiple partners or
HCFS/hospitals/laboratories will be asked to specify country and partner/facility name on each
form.  

Name of partner* or project site (HCF or
laboratory):  
*We are defining "partner" broadly to include partners
[pilot_recipname] regularly collaborates with or
engages aspart of the activities for this project.
This can include national and sub-national level
government ministries; individual healthcare
facilities, hospitals and/or individual laboratories;
academic partners; other non-governmental
organizations (NGOs); etc.). 

__________________________________

Is this partner a laboratory or HCF/hospital with lab?

Yes
No

2. Select the option that best describes this partner:

Government ministry (national or sub-national)
Private Industry
Academic Institution
NGO
Other (specify): ______

2.   Select the option that best describes the
laboratory or healthcare facility site:

3. Partner or laboratory/HCF location (e.g., name of
district/province, etc.):

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State or provincial level
District, town or local level site
Other (specify): ______
(If unknown, enter 'N/A')

__________________________________
(If none or unknown, enter 'N/A')

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4. Country:

5. List project contribution(s) from this partner
and/or laboratory site: 
(e.g., equipment and supplies procured; trainings
provided; isolates collected and submitted; etc.)

__________________________________
(If none or unknown, enter 'N/A')

__________________________________________
(If none or unknown, enter 'N/A')

SECTION 1: PROJECT IMPLEMENTATION PHASE
6. Select the implementation phase that best describes
the project as it currently stands with this partner
or site:

a. Exploration - Engaging stakeholders to identify 1.
need(s); and 2. appropriate steps to address gaps or
enhance activities

Exploration
Initiation
Initial Implementation
Full Implementation
Expansion/Scale-Up
Reduction/Scale Down

b. Initiation - Project planning; consensus reached
with stakeholders regarding project sites, objectives,
and activities, as well as timeline for implementation
c. Initial Implementation - Beginning stages of
project implementation at selected sites including:
Collection of baseline data; Establishing new
practices/protocols; Supply/equipment procurement;
Recruitment/hiring of locally based staff; etc. d.
Full Implementation - Majority of project activities
have been rolled out and routinely monitored
e. Expansion/Scale-Up - Increasing the number of sites
targeted for project activities
f. Reduction/Scale Down - Decreasing the number of
sites targeted for project activities or scaling down
scope of activities
Please use this space to provide any additional
context or information about project implementation
phase with this partner or site.

__________________________________________

SECTION 2: LABORATORY NETWORK ACTIVITIES (only for lab or HCF/hospital level sites)
7. Does this site participate in a laboratory network
or referral network?

Yes
No
Don't Know
Does not apply

8. Has this site agreed to (or is it required to)
submit or forward isolates?

Yes
No
Don't Know
Other (specify): ______

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9. Which of the following testing methods are
routinely performed at this laboratory or HCF  site?
(Select all  that apply)

Culturing
Antimicrobial Susceptibility Testing (AST) (e.g.,
e test, disk diffusion, broth microdilution)
Phenotypic Testing (e.g., MALDI-TOF, Vitek2, API,
etc.)
Genotypic Testing/ Polymerase chain reaction (PCR)
- Describe test methods, including targets and any
automated platforms
Sequencing (e.g., WGS, short-read Illumina,
long-read ONT, direct amplicon sequencing, NGS,
etc.)
Other (specify): ______
Unknown
None of these

a. Culturing

i. Testing methods performed

______
ii. Total testing volume (during current budget period):

______
iii. Total number of personnel that received training in culturing:  ______
b. Antimicrobial Susceptibility Testing (AST and AFST) (e.g., e test, disk diffusion, broth microdilution)
i. Testing methods performed

______
ii. Total testing volume (during current budget period):

______
iii. Total number of personnel that received training in culturing:  ______
c. Phenotypic Testing (e.g., MALDI-TOF, Vitek2, API, etc.)
i. Testing methods performed

______
ii. Total testing volume (during current budget period):

______
iii. Total number of personnel that received training in phenotpyic testing (during current budget period): 

______

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d.  Genotypic Testing/ Polymerase chain reaction (PCR) - Describe test methods, including targets and any
automated platforms
i. Testing methods performed, including targets and any automated platforms

______
ii. Total testing volume (during current budget period):

______
iii. Total number of personnel that received training in this testing method:

______
e. Sequencing (e.g., WGS, short-read Illumina, long-read ONT, direct amplicon sequencing, NGS, etc.)
i. Testing methods performed, including targets and any automated platforms

______
ii. Total testing volume (during current budget period):

______
iii. Total number of personnel that received training in this testing method:

______
iv. Total numbe rof personnel trained to perform bioinformatics analysis of WGS data:
______
v. Describe the bioinformatics pipelines being utilized to analyze data:
______
f.  Other Testing Method
i. Testing methods performed

______
ii. Total testing volume (during current budget period):

______
iii. Total number of personnel that received training in this testing method:

______

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10.  Does this site have a program or any activities
that focus on retaining staff with institutional and
technical knowledge once they are trained on any of
the testing methods listed previously?

Yes
No
Don't Know
Does not apply

10.a. If yes, please describe:
__________________________________________
11. Describe how laboratory data and results are
managed and what platform (e.g., Laboratory
Information Management System (LIMS), etc.) is used
for data management at this laboratory/facility. 

__________________________________________

Where applicable, describe data management in the
field or at point of collection (e.g., environmental
surveillance sites, etc.) as well as in the lab. 
Thank you for completing this form. Please be sure that Form 1 is completed as well.
For any assistance, please email [email protected].

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