Patient Information

Form Approved
OMB No. 0920-0852
Exp. Date xx/xx/xxxx

HAI & ANTIMICROBIAL USE PREVALENCE SURVEY
PATIENT INFORMATION FORM
-

CDC ID:

/

Survey date:

/

:

If data collected on survey date, enter data collection time:

Data collector initials:

am

pm

Data collection done retrospectively

OR

I. Identifiers (NOT transmitted to CDC)
Patient name:

Date of birth (mm/dd/yyyy):

Hospital name:

Hospital unit name:

Room number:

Medical record no.:

/

/

II. Demographic information
Age:

yrs

mos

dys

Sex at birth:
Male
Race:

Female

/

Admission date (mm/dd/yyyy):

Unknown

/

CDC location code:

Unknown

Ethnicity:

(check all that apply)

Primary Payer:

American Indian or Alaska Native

White

Hispanic or Latino

Medicare

No charge

Black or African American

Other race

Non-Hispanic or Latino

Medicaid

Other

Native Hawaiian/other Pacific Islander

Unknown

Unknown

Private insurance

Unknown

Asian

Self-pay

III. Weight and height
Weight:
OR

lbs.
kg

Height:

oz.

ft.

OR

Unknown

BMI:

in.

cm

(record only if height or weight unavailable)

Unknown

Unknown

NA

IV. Devices and pressure injuries/ulcers present on the survey date
Urinary catheter:
Central line:

Yes

Yes

No

Pressure injuries or ulcers :

No

Unknown

Unknown
Yes

No

Ventilator:

Yes

If “Yes,” indicate how many lines:

No
1 line

Unknown
>1 line

Unknown

Unknown

If “Yes,” were all pressure injuries or ulcers that were present on the survey date present on admission?
Indicate the highest stage of the pressure injuries or ulcers on the survey date :

Stage 1

Yes

Stage 2

Unstageable

No
Stage 3

Unknown
Stage 4

Unknown

V. Antimicrobials
Antimicrobials administered or scheduled to be administered:
On the survey date:

Yes

No

Unknown

On the day before the survey date:

Yes

No

Unknown

VI. Follow-up information

/

Enter date of follow-up data collection:
Hospital discharge date:

/

Patient outcome at time of hospital discharge:

/

/

OR check one:
Survived

Died

Unknown

Unknown

Still in hospital

Still in hospital

Public reporting burden of this collection of information is estimated to average 17 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 Information Collection Request Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30329; ATTN: PRA (0920-0852).

HAIPS 2020_20190603

CS302660