Form 0920-0852 AttachmentC_0920-0852_OMBApprovedDataCollectionForm

Form Approved

OMB No. 0920-XXXX

Exp. Date xx/xx/20xx

Form Approved

OMB No. 0920-XXXX

Exp. Date xx/xx/20xx

Form Approved

OMB No. 0920-XXXX

Exp. Date xx/xx/20xx

HAI & ANTIMICROBIAL USE POINT PREVALENCE SURVEY

Form Approved

OMB No. 0920-0852

Exp. Date 05/31/2013

PRIMARY TEAM / EIP TEAM DATA COLLECTION FORM

CDC ID: - Survey date: // Data collector initials: _____

I. Identifiers (for Primary Team and EIP Team use only; identifiers are not transmitted to CDC)
Patient name: ___________________________________ (Last, First, MI)	Date of birth: //
Hospital name: __________________________________	Hospital unit name: ______________________________
Room number: __________________________________	Medical record no.: ______________________________

II. Demographics
Age: _______ years months days		Admission date: //
Gender: M F Unknown		CDC location code: __________________________
Race (check all that apply): American Indian or Alaska Native Black or African American Native Hawaiian or other Pacific Islander Asian	White Other race Unknown		Ethnicity: Hispanic or Latino Not Hispanic or Latino Unknown

III. Risk factors (in place on the survey date)
Urinary catheter:	No Yes Unknown
Ventilator:	No Yes Unknown
Central line:	No Yes  Unknown	If “Yes,” check all that apply: PICC Femoral line Other central line Unknown

IV. Antimicrobials
On antimicrobials on the survey date or the calendar day prior to the survey date:	No Yes Unknown
**Qualification for hemodialysis and peritoneal dialysis patients ONLY** On any of the following antimicrobials in the 4 calendar days prior to the survey date: vancomycin, amikacin, gentamicin, tobramycin, streptomycin, kanamycin 	NA, not a dialysis patient No Yes Unknown

FORM IS COMPLETE

Public reporting burden of this collection of information is estimated to average 7 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 30333; ATTN: PRA 0920-0852.

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