Instructions for data collection

Attachment J:
Healthcare Facility Assessment (HFA) Form Instructions
HFA Overview
•

The hospital should designate one staff member (e.g., Infection Preventionist) to ensure
completion of the HFA and to submit the completed form to the EIP Team Project Coordinator.


This staff member should consult as needed with other hospital departments or
colleagues to answer the questions included in the HFA. The name(s) and
department(s) of any individuals who provide information should be recorded under
Sources of information on pg. 1 of the form.

•

The HFA has four sections:
I. Information about person responsible for ensuring completion of assessment and submission
to EIP Team (e.g., Infection Preventionist)
II. Hospital data (e.g., licensed beds, staffed beds, etc.)
III. Infection prevention and control (e.g., policies, procedures, infection control team/program,
etc.)
IV. Antimicrobial stewardship (e.g., policies, procedures, stewardship team, etc.)

•

The HFA should be completed using the most up-to-date information available. For example, if
information on the No. FTE Infection Preventionists is available from the years 2018 and 2019, the
2019 information should be used.

•

In addition, efforts should be made to answer each question completely. If after consulting with
appropriate departments hospital staff are unable to obtain the required information for a question,
they may select Unknown if the response option is available. For questions where Unknown is not
an available response option, hospital staff may check Other (specify) and enter “Unknown.” Note:
the EIP Team Project Coordinator will follow-up with hospital staff to confirm that question(s)
with Unknown responses cannot be answered.

•

The HFA should be completed and returned to the EIP Team Project Coordinator within 1-2
weeks. Hospital staff should contact the EIP Team Project Coordinator if they have any questions
or need assistance in completing the form.

•

Please refer to other sections of the Operational Manual for additional guidance.

Page 1 of 10

HFA Questions
Data Fields or Questions
Sources of information

Section I: Info About Person
Responsible for Ensuring Completion
of Assessment and Submission to EIP
Team
Section II: Hospital Data

Instructions for Data Collection
Person(s) or department(s) to contact for information.
This information is for hospital and EIP Team use
only and will not be transmitted to CDC.
Required. Enter the name of the person and department
responsible for ensuring completion and submission of
this form.

Q2: Which of the following best describes
your role in the hospital?

Required. Enter the name(s) of the person(s) and
department(s) responsible for providing information on
hospital data.
Required. Enter the name(s) of the person(s) and
department(s) responsible for providing information on
infection prevention and control.
Required. Enter the name(s) of the person(s) and
department(s) responsible for providing information on
antimicrobial stewardship.
Information about person responsible for ensuring
completion of assessment and submission to EIP
Team
Required. Record the date when you first start filling out
the form using this format: MM/DD/YYYY
Example: 06/08/2020
Required. Check one role that best describes your role in
the hospital at the time you are completing this form.

Section II.
Q3: Complete the following table for your
hospital using the most up-to-date data
available to you.

If none of the options describe your current role in the
hospital, check Other (specify) and describe your role.
Hospital data
Required. Answer all questions in the table using the
most up-to-date data available to you at the time you are
completing this form.

Section III: Infection Prevention and
Control
Section IV: Antimicrobial Stewardship

Section I.

Q1: Enter the date you started to complete
the assessment:

No. of acute care licensed beds

For each question in the table, you will enter or check a
numeric value and check the year from which the data
was most recently available. If the most recent data are
available from a year other than 2018 or 2019, check
Other and enter the year.
Required. Enter the number of acute care licensed beds
in your hospital (3-digit, e.g., 399). Do not include
nursing home or skilled nursing facility beds in the
count.
If after consulting with appropriate departments you do
not have access to this information, check Unknown.
Page 2 of 10

No. of acute care staffed beds

No. of full-time equivalent
(FTE) infection preventionists

Required. Enter the number of acute care staffed beds in
your hospital (3-digit, e.g., 389). Do not include nursing
home or skilled nursing facility beds in the count.
If after consulting with appropriate departments you do
not have access to this information, check Unknown.
Required. Calculate the number of full-time equivalent
(FTE) infection preventionists (IPs) in your hospital.
Enter the number of FTEs to the nearest hundreth of an
FTE (e.g., 2.253 FTEs would round to 2.25 FTEs).
To calculate this value, you will need to know the
percentage of the time each person works on infection
control. (e.g., Full-time = 1 FTE; Half-time = 0.5 FTE;
30% of the time = 0.3 FTE)
Example: There are three infection preventionists in your
hospital. The first one is full time (1 FTE), the second is
half-time (0.5 FTE), and the third spends 75% of his/her
time on infection control (0.75 FTE). The total infection
preventionists in your hospital is 2.25 (1 +0.5+0.75).
If your hospital does not have any infection
preventionists, check None.

No. of FTE physician hospital
epidemiologists

If after consulting with appropriate departments you do
not know if your hospital has any infection preventionists
or you do not know the number, check Unknown.
Required. Calculate the number of full-time equivalent
(FTE) physician hospital epidemiologists in your
hospital. Enter the number of FTEs to the nearest
hundreth of an FTE (e.g., 2.252 FTEs would round to
2.25 FTEs).
NOTE: Physician epidemiologist refers to a physician
who officially functions as a hospital epidemiologist
(e.g., investigating outbreaks, interpreting data,
developing policies/procedures, etc.). Only include
infectious diseases physicians if they function in the
capacity noted above.
Example: There are three physicians who work as
hospital epidemiologists in your hospital. The first is
full-time (1 FTE), the second is half-time (0.5 FTE), and
the third spends 75% of his/her time as a hospital
epidemiologist. The total FTE physician hospital
epidemiologists in your hospital is 2.25 (1+0.5+.75).
Page 3 of 10

If your hospital does not have any physician hospital
epidemiologists, check None.

No. of FTE interns/residents

If after consulting with appropriate departments you do
not know if your hospital has any physician hospital
epidemiologists or you do not know the number, check
Unknown.
Required. Calculate the number of full-time equivalent
(FTE) interns/residents in your hospital. Enter the
number of FTEs to the nearest hundredth of an FTE (e.g.,
50.253 FTEs would round to 50.25 FTEs).
This information may be available from one of your
hospital’s administrative departments, such as the finance
department or other department that is responsible for
Medicare-related issues.
Example: There are fifty interns/residents in your
hospital. Twenty-five are full-time (1 FTE) and 25 are
half-time (0.5 FTE). The total FTE interns/residents in
your hospital is 37.50 [25(1.0)+25(0.5)].
If your hospital does not have any interns or residents,
check None and skip to Question #4.

If your hospital has interns or
residents: Provide the official
intern/resident to bed ratio
(IRB)

If after consulting with appropriate departments you do
not know if your hospital has any interns or residents or
you do not know the number, check Unknown.
Required. This information may be available from one
of your hospital’s administrative departments, such as the
finance department or other department that is
responsible for Medicare-related issues. You are not
expected to calculate this ratio yourself.
If after consulting with appropriate departments you do
not know your hospital’s intern/resident bed ratio, check
Unknown.

Q4: For each type of the unit in your
hospital, check the one ratio that most
accurately reflects the average Registered

Resident is defined according to the Code of Federal
Regulations (CFR) § 413.75(b): “resident means an
intern, resident, or fellow who is formally accepted,
enrolled, and participating in an approved medical
residency program, including programs in osteopathy,
dentistry, and podiatry, as required in order to become
certified by the appropriate specialty board.”
Required. Select the one ratio that best reflects the
average RN to patient ratio during dayshift hours for
each of the locations listed.
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Nurse (RN) to patient ratio during
dayshift hours:

NOTE: This should reflect the actual and most up-todate, rather than ideal, ratio. Refer to Appendix 1 of the
Operational Manual for assistance for more information
on location mapping.
Example: A ratio of 1:5 would mean one RN for every
five patients.
If you do know the ratio for a location, but it does not
meet one of the options listed, check Other (specify) and
enter the ratio in the same format as the options listed
(e.g., 1:7).
If your hospital does not have a particular location, check
NA.
If your hospital does have the location but you are unable
to find out the RN to patient ratio after consulting with
appropriate departments, check Unknown.
Infection prevention and control
Required. Check Yes if your hospital has an infection
control team or program with at least one staff member
responsible for implementing infection control
policies/practices and related activities. Otherwise, check
No and skip to Question #9.

Section III.
Q5: Does your facility have an infection
control team or program with at least one
staff member responsible for developing
and implementing infection control
policies and practices and related
activities?
Note: Questions 6-8 are Required if you checked Yes to Question # 5. If you checked No to
Question # 5, you can skip to Question # 9
Q6: If your hospital has an
Check all job categories of individuals who participate in
infection control team/program,
the infection control team/program.
who participates in the infection
control team/program (check all
If none of the available options describe the member(s)
that apply)?
of the team/program, check Other (specify) and provide
the job category of the member(s).
Q7: If your hospital has an
Check one answer that best reflects the number of years
infection control team/program,
the infection control team/program has been in place in
how long has the infection
your hospital.
control team/program been in
place (check one)?
Q8: If your hospital has an
Check one answer that best reflects the frequency of the
infection control team/program,
infection control team/program’s meetings in your
how often does the team/program hospital.
meet (check one)?
Q9: Is there a committee in your hospital
Required. Check Yes if there is a committee (another
that reviews infection control-related
group of hospital staff) that reviews infection controlactivities (such as reports, policies and
related activities. Otherwise, check No and skip to
procedures, etc.)?
Question #12.

Page 5 of 10

Note: Questions 10-11 are Required if you checked Yes to Question # 9. If you checked No to
Question # 9, you can skip to Question # 12
Q10: If there is a committee in
Check all job categories represented on the infection
your hospital that reviews
control committee.
infection control-related
activities, indicate the members
If none of the available options describe the member(s)
represented on the committee
of the committee, check Other (specify) and provide the
(check all that apply):
job category of the member(s).
Q11: If there is a committee in
Check one answer that best reflects the frequency of the
your hospital that reviews
infection control committee’s meetings in your hospital.
infection control-related
activities, how frequently does
this committee meet (check
one)?
Q12: For each HAI surveillance statement Required. Check Yes, No, or Unknown for all statements
below, check Yes, No, or Unknown to
in the table to indicate what is currently being done in
indicate what is currently being done in
your hospital at the time of this assessment, or during the
6 months prior to this assessment.
your hospital (at the time of this
assessment, or during the 6 months prior
to this assessment):
Q13: For each infection control policy
Required. Check Yes, No, or Unknown for all statements
statement below, check Yes, No, or
in the table to indicate whether the policies listed are in
Unknown to indicate whether a policy is
place in your hospital at the time of this assessment.
in place in your hospital at the time of this
assessment:
Q14: For each statement about monitoring Required. Check Yes, No, or Unknown for all statements
adherence to infection control policy,
in the table to indicate what is currently being done to
check Yes, No, or Unknown to indicate
measure adherence to infection control policies in your
what is currently being done in your
hospital at the time of this assessment, or during the 6
hospital (at the time of this assessment, or months prior to this assessment.
during the 6 months prior to this
assessment):
Q15: When does your hospital require
Required. Check all statements that apply to policies for
staff members to participate in training on infection control training in your hospital.
infection control topics (check all that
apply)?
If staff members participate in required training on a
regular basis, also check the one answer that best
describes the frequency of regular training.
If none of the statements reflect the requirement or the
time when staff members are required to participate in
infection control training, check Other (specify) and
describe the infection control training requirement in
your hospital.
Q16: For each multidrug-resistant
Required. Check Yes, No, or Unknown for all statements
organism (MDRO) management statement in the table(s) below to indicate what is being done to
below, check Yes, No, or Unknown to
manage multidrug-resistant organisms in your hospital at
indicate what is currently being done in
the time of this assessment.
Page 6 of 10

your hospital at the time of this
assessment.
Q17: What is the primary testing method
for Clostridioides difficile (C.difficile)
used most often by your hospital’s
laboratory or the outside laboratory where
your hospital’s testing is performed
(check one)?

Q18: Which of the following
Clostridioides difficile (C.difficile)
infection control practices are performed
in your hospital (check all that apply)?

Required. Check the one answer that describes the
testing method most frequently used for C. difficile
testing in your hospital’s lab or in the outside lab (if your
hospital performs C. difficile testing in an outside lab).
If none of the testing methods listed describes the method
most frequently used, check Other (specify) and describe
the testing method used most frequently.
Required. Check all statements that indicate the
infection control practices performed in your hospital for
C. difficile.
If your hospital performs an infection control practice not
listed in the options, check Other (specify) and describe
the practice.

Q19: If your hospital does not have a
sufficient number of private rooms
available, what does your hospital do with
patients who are identified with active
Clostridioides difficile (C.difficile)
infection (check all that apply)?

Q20: For patients with active
Clostridioides difficile (C.difficile)
infection, what is the preferred method of
hand hygiene used in your hospital (check
one)?

Q21: In what settings and/or patients does
your hospital routinely perform
Methicillin-resistant Staphylococcus
aureus (MRSA) surveillance testing
(culture or PCR) on admission for the

If your hospital does not perform any of the infection
control practices listed, check None of the above.
Required. Check all statements that indicate what your
hospital does to address patients with active C. difficile
infection if there are not enough private rooms available.
If there are enough private rooms available or if all
rooms in your hospital are private, check Not Applicable.
If your hospital does not have enough private rooms, but
your hospital addresses patients with active C. difficile
infection in a different way than the options listed, check
Other (specify) and describe how your hospital addresses
these patients.
Required. Check one hand hygiene method that is
preferred for patients with active C. difficile infections in
your hospital.
If both soap/water and alcohol hand gel are available for
use in your hospital, but neither method is preferred,
check Not Specified.
If your hospital prefers a hand hygiene method other than
soap/water or alcohol hand gel, check Other (specify) and
describe the method your hospital prefers.
Required. Check all settings and/or patients where your
hospital routinely (i.e., as part of standard processes)
performs MRSA surveillance testing (culture or PCR) on
admission to detect MRSA colonization (i.e., active
surveillance).
Page 7 of 10

purpose of detecting MRSA colonization
(active surveillance)? (check all that
apply)

If your hospital performs (active) MRSA surveillance
testing on admission in settings and/or patients not listed
in the options, check Other (specify) and describe the
settings and/or patients where active surveillance for
MRSA testing occurs on admission.
If your hospital does not routinely perform (active)
MRSA surveillance testing on admission in any settings
and/or patients, check None of the Above.

Q22: In what settings and/or patients does
your hospital routinely use chlorhexidine
bathing (check all that apply)?

Required. Check all settings and/or patients where your
hospital routinely (i.e., as part of standard processes)
performs chlorhexidine bathing.
If your hospital routinely performs chlorhexidine bathing
in settings and/or patients not listed in the options, check
Other (specify) and describe the settings and/or patients
where routine chlorhexidine bathing occurs.

Q23: In what settings and/or patients does
your hospital routinely use mupirocin
(check all that apply)?

If your hospital does not routinely perform chlorhexidine
bathing in any settings and/or patients, check None of the
Above.
Required. Check all settings and/or patients where
mupirocin is routinely (i.e., as part of standard processes)
used in your hospital.
If your hospital routinely uses mupirocin in settings
and/or patients not listed in the options, check Other
(specify) and describe the settings and/or patients where
routine mupirocin use occurs.

Section IV.
Q24: Does your hospital have a
multidisciplinary team focused on
promoting appropriate antimicrobial use
(antimicrobial stewardship)?

If your hospital does not routinely use mupirocin in any
settings and/or patients, check None of the Above.
Antimicrobial stewardship
Required. Check Yes if your hospital has a
multidisciplinary team that focuses on promoting
appropriate antimicrobial use (i.e., antimicrobial
stewardship team). Otherwise, check No and skip to
Question #29.

Note: Questions 25-28 are Required if you checked Yes to Question # 24. If you checked No to
Question # 24, you can skip to Question # 29
Q25: If your hospital has an
Check all job categories describing members of the
antimicrobial stewardship team,
antimicrobial stewardship team in your hospital.
who participates in the
stewardship team (check all that
apply)?
Page 8 of 10

Q26: If your hospital has an
antimicrobial stewardship team,
how long has the team has been
in place (check one)?
Q27: If your hospital has an
antimicrobial stewardship team,
how often does the team meet
(check one)?
Q28: If your hospital has an
antimicrobial stewardship team,
what type of support does the
team receive from hospital
administration (check all that
apply)?

If none of the available options describes the member(s)
of the stewardship team, check Other (specify) and
provide the job category that describe the member(s).
Check one answer that best reflects the number of years
the antimicrobial stewardship team has been in place in
your hospital.
Check one answer that best reflects the frequency of the
antimicrobial stewardship team’s meetings in your
hospital.
Check all types of formal (i.e., salary, recognition as
committee, etc.) support that hospital administration
provides to the antimicrobial stewardship team.
If your hospital’s stewardship team receives a type of
formal support not listed in the options, check Other
(specify) and describe the type of formal support.
If your hospital’s stewardship team does not receive
formal support from administration, check No formal
support from administration.
Required. Check Yes, No, or Unknown for all statements
reflecting antimicrobial use policies and practices in
place in your hospital at the time of this assessment.

Q29: For each statement listed below,
regardless of whether your hospital has an
antimicrobial stewardship team, check
Yes, No, or Unknown to indicate policies
or practices in place in your hospital at the
time of this assessment.
Q30: Is antimicrobial consumption
Required. Check Yes if antimicrobial consumption (i.e.,
monitored in your hospital?
use of antimicrobials, such as antibiotics) is monitored in
your hospital. Otherwise, check No and STOP as the
Healthcare Facility Assessment is complete.

Note: Questions 31-34 are Required if you checked Yes to Question # 30. If you checked No to
Question # 30, you are finished with this assessment.
Q31: If antimicrobial
Check all settings where antimicrobial consumption
consumption is monitored in
patterns (e.g., use by type of antimicrobial, such as class
your hospital, in what settings
or drug name) are monitored in your hospital.
are antimicrobial consumption
patterns monitored (check all
If antimicrobial consumption patterns are monitored but
that apply)?
not in settings listed in the options, check Other (specify)
and describe the setting(s) where they are monitored in
your hospital.
Q32: If antimicrobial
Check all sources of data used for monitoring
consumption is monitored in
antimicrobial consumption (i.e., use) in your hospital.
your hospital, what are the data
sources for monitoring
Page 9 of 10

antimicrobial consumption
(check all that apply)?
Q33: If antimicrobial
consumption is monitored in
your hospital, what are the
measures used to monitor
antimicrobial consumption
(check all that apply)?
Q34: If antimicrobial
consumption is monitored in
your hospital, to who in the
hospital are antimicrobial
consumption data reported
(check all that apply)?

If your hospital uses a data source not listed in the
options, check Other (specify) and describe the data
source.
Check all measures used for monitoring antimicrobial
consumption (i.e., use) in your hospital.
If your hospital uses measures not listed in the options,
check Other (specify) and describe the measures used.
Check all individuals or teams to whom antimicrobial
consumption data (i.e., use) are reported in your hospital.

If antimicrobial consumption data are reported to
individuals or teams not listed in the options, check
Other (specify) and describe to whom these data are
reported.
The Healthcare Facility Assessment is complete.

Page 10 of 10

Attachment J:
Patient Information Form (PIF)Instructions
PIF Overview
•

The PIF will be completed for eligible patients identified using a random sample of inpatients
present in the facility on the day of the survey. These forms may be completed by hospital staff
and/or the EIP Team, depending on the hospital’s resources.

•

The PIF has six sections:
I. Identifiers [Not transmitted to CDC] (e.g., Patient name, hospital name, etc.)
II. Demographic information (e.g., Age, admission date, race, etc.)
III. Weight and height (i.e., Weight, height, or BMI)
IV. Devices and pressure injuries/ulcers present on the survey date (i.e., Urinary catheter,
ventilator, central lines, pressure injuries/ulcers)
V. Antimicrobials (i.e., if administered on survey date or day before)
VI. Follow-up information (i.e., Discharge date and outcome)

•

It is highly recommended that Sections I – V be completed on the survey date. Section VI must
be completed retrospectively because it contains discharge and outcome information.

•

All PIFs must be completed and returned to the EIP Team Project Coordinator within 30 days
of the survey date. Hospital staff should contact the EIP Team Project Coordinator if they have
any questions regarding the PIF.

•

Please refer to other sections of the Operational Manual for additional guidance.

Page 1 of 15

PIF Fields/Questions

Data Fields or Questions

Instructions for Data Collection

CDC ID

Required. Enter the unique, 7-digit, alphanumeric CDC ID for the
patient being reviewed.
2-digit (character) state abbreviation (e.g., TX)
2-digit (character) hospital code (e.g., AA)
3-digit (numeric) patient code (e.g., 010)
Example: TX-AA010
Required. Enter the numeric survey date for your hospital in the format
MM/DD/YYYY.
Example: 05/01/2020
Required. Enter data collector’s (i.e., your) initials.
Example: MJ
Required. If data was collected on the survey date, enter the time of
data collection and check AM or PM.
Example: 08:10
am
Example: 02:30
pm

Survey Date

Data collector initials
If data collected on survey
date, enter data collection
time

Data collection done
retrospectively
Section I.
Patient name

Date of birth (mm/dd/yyyy)

Hospital name
Hospital unit name

Room no.

Medical record no
Section II.
Age

Required. If data was collected after the survey date, check this box.
Note: If data are collected retrospectively, only collect information
present, specimens collected, and tests performed up until 1700 hours
(5:00 pm) on the survey date.
Identifiers (This information is not transmitted to CDC)
Required. Enter the patient’s name in the following format:
Last Name, First Name, Middle Initial
Example: Doe, Jane R.
Required. Enter the patient’s date of birth in the following format:
MM/DD/YYYY
Example: 06/08/1970
Required. Enter the name of the hospital.
Example: Central Park Hospital
Required. Enter the name of the hospital unit in which the patient is
location at the time of the survey.
Example: Surgery
Required. Enter the number of the room occupied by the patient at the
time of the survey.
Example: 410
Required. Enter the patient’s medical record number.
Example: 6645312
Demographic information
Required. Enter the patient’s age on the day of the survey. Age may be
noted on the medical record “face sheet.”
If patient’s age is less than 30 days, indicate age in days and check the
dys box. If patient’s age is 30 days to 11 months, indicate age in months
and check the mos box. If patient’s age is equal to or greater than 12
Page 2 of 15

months, indicate age in years and check the yrs box.
If after review of the patient’s medical record, you are unable to find
the patient’s age, check Unknown.

Admission date
(mm/dd/yyyy)

Examples:
• Patient is 29 days old, enter 29 and check the dys box.
• Patient is 31 days old, enter 1 and check the mos box.
• Patient is 11 months old, enter 11 and check the mos box.
• Patient is 13 months old, enter 1 and check the yrs box.
Required. Enter the patient’s admission date as recorded in the medical
record using the following format:
MM/DD/YYYY
Example: 04/28/2020
Admission date may be noted on the medical record “face sheet.” You
should enter the actual hospital admission date, even in circumstances
where the patient has stayed overnight in the Emergency Department
waiting for admission. Note that in other data fields on the survey
forms, special instructions are provided for how to handle data
collected in the Emergency Department on the day prior to inpatient
admission.

Sex at birth

CDC location code

On occasion, you may encounter a patient who is on “observation”
status and not officially a hospital inpatient. These patients qualify for
inclusion in the survey if they are in an acute care unit inpatient bed and
they have been in the hospital for ≥24 hours at the time of the survey.
Because they are not considered hospital inpatients, there may not be a
hospital admission date. In these cases, enter the date that the patient
was brought to the acute care inpatient bed as the admission date for the
purposes of the prevalence survey.
Required. Enter the biological sex of the patient at birth. This
information may be found on the medical record “face sheet.”
If this information is not available in the medical record, check
Unknown.
Required. Enter the CDC location code for the patient.
Example: W-S
(i.e., “Inpatient Surgical Ward”)
The CDC location code identifies the type of inpatient unit in which the
patient is located on the day of the survey. CDC location codes appear
in Appendix 1 of the Operations Manual. Hospital units should be
mapped to the appropriate CDC location codes in advance of the survey
date. The CDC location code for the unit of each bed number selected
for inclusion in the survey should appear on the randomly-sorted bed
number list that the EIP Team provides to Hospital Staff Primary Team
to use on the survey date. Record this code on the PIF.
Page 3 of 15

Only one CDC location should be recorded on the PIF. If bed numbers
from heterogeneous units (those units with multiple patient types, and
with no single patient type comprising 80% or more of the unit’s
population) are included on the randomly sorted bed number list, and
there are multiple possible CDC location codes that could potentially be
assigned, depending upon the type of patient occupying the bed on the
day of the survey, you should select the single most appropriate code
based on the type of patient or the clinical service to which the patient
was admitted.

Race

Example: Bed 100 on Unit 6 East is included in the survey. 6 East is a
unit with the following patient types: 30% general medicine, 40%
orthopedic surgery, 30% hematology/oncology. On the randomly-sorted
bed number list, the CDC location column has the following entry: WM or W-ORT or W-ONCHONC. You should evaluate the medical
record for the patient in Bed 100 on the day of the survey and record
one CDC location code based on the patient type or clinical service. If
the patient is admitted to the medical service for treatment of
pneumonia, for example, you would record only W-M on the PIF.
Required. Check all race selections that apply to the patient as noted in
the medical record. Race may be found on the medical record “face
sheet.” Do not make assumptions based on name or native language.
If race is not specified in the medical record and/or if you are unsure of
the patient’s race, check Unknown.
The minimum categories for the Federal statistics of race data are
defined as follows:
American Indian or Alaskan Native: A person having origins in any of
the original peoples of North and South America (including Central
America) and who maintains tribal affiliation or community
attachment.
Asian: A person having origins in any of the original people of the Far
East, Southeast Asia, or the Indian subcontinent including the
following: Cambodia, China, India, Japan, Korea, Malaysia, Pakistan,
the Philippine Islands, Thailand, and Vietnam.
Black or African American: A person having origins in any of the black
racial groups of Africa.
Native Hawaiian or other Pacific Islander: A person having origins in
any of the original peoples of Hawaii, Guam, Samoa, or other Pacific
Islands.

Page 4 of 15

White: A person having origins in any of the original peoples of
Europe, the Middle East, or North Africa.
Additional category specified in the Health Cost and Utilization Project
(HCUP) and National Inpatient Sample (NIS):
Other Race: Some hospitals may specify Other Race in the medical
record. Check this category if specified in the medical record.
NOTE: Some hospitals may combine race/ethnicity coding. For
example, they might define a person’s race as Hispanic or Latino. In
this case, race should be reported as Unknown, and ethnicity should be
Hispanic or Latino.

Ethnicity:

If a patient’s race as noted in the medical record is not listed as an
option on the PIF, reference the U.S. Census Bureau standards on race
and ethnicity to determine how to classify it as one of the races listed on
the PIF: https://www.census.gov/topics/population/race/about.html
Required. Check one ethnicity for the patient as noted in the medical
record. Ethnicity may be found on the medical record “face sheet.”
Complete ethnicity even if race is already indicated. Do not make
assumptions based on name or native language.
If ethnicity is not specified in the medical record and/or if you are
unsure of the patient’s ethnicity, check Unknown.
NOTE: Hispanic or Latino ethnicity indicates a person of Cuban,
Mexican, Puerto Rican, South or Central American, or other Spanish
culture or origin, regardless of race. For example, many Whites are
also Hispanic or Latino.
Some hospitals may combine race/ethnicity coding. For example, they
might define a person’s race as Hispanic or Latino without any
additional information. In this case, race should be reported as
Unknown, and ethnicity should be Hispanic or Latino. If White is
indicated in the medical record without any additional information, race
should be reported as White and ethnicity should be reported as
Unknown. If Mixed Race is indicated in the medical record without any
additional information on categories of race and/or ethnicity, race
should be reported as Other, and ethnicity should be reported as
Unknown.
If a patient’s ethnicity as noted in the medical record is not listed as an
option on the PIF, reference the U.S. Census Bureau standards on race
and ethnicity to determine how to classify it as one of the ethnicities
listed on the PIF:
https://www.census.gov/topics/population/race/about.html
Page 5 of 15

Primary Payer

Required. Check one primary type of health insurance as noted in
patient’s medical record. If a patient’s insurance status changes during
hospitalization, indicate insurance status at time of admission. Do not
report secondary insurance.
If the primary health insurance type is not noted in the patient’s medical
record, check Unknown.
Descriptions of Primary Payer Types:
Medicare: the national health insurance program for people 65 years
and older (also covers some people under the age of 65 with disabilities
and people with end-stage renal disease).
Medicaid: the program that pays for medical assistance for certain
people with low incomes and resources. State assistance programs are
those state programs that provide medical coverage to individuals who
are otherwise uninsured, uninsurable, or those with special health care
needs.
Some Medicaid programs are called “Medical Assistance Program”,
“Title 19”, or “{State} Medicaid, such as “California Medicaid”. CHIP
or S-CHIP programs can also be under “Title XXI Program” or
“{State} Chip, such Maryland Children’s Health Program. Medicaid
and public assistance programs are listed below by state (this is from
the 2019 ABCs CRF Instructions):

State
CA

Medicaid
Medi-Cal;
Health
Insurance
Premium
Payment
Program (HIPP)

CHIP
Healthy
Families
Program
(HFP)

CO

Primary Care

Child Health

State/Other program
Access for Infants &
Mothers (AIM); County
Medical Services
Program (CMSP);
California Children’s
Services (CCS); Major
Risk Medical Insurance
Program (MRMIP);
CARE Health Insurance
Premium Payment
Program; California
Major Risk Medical
Insurance Program;
Healthy Kids Program
Health Care Program for
Page 6 of 15

Physician
Program
(PCPP); Baby
Care/Kids Care;
Health Colorado

Plan Plus
(CHP +);
Children’s
Basic Health
Plan

CT

Medical
Assistance
Program; Husky
Part A

The HUSKY
Plan;
HUKSY
Plus;
HUSKY Part
B

GA

Right from the
Start (RSM);
Health
Insurance
Premium
Payment
Program
(HIPP); Katie
Beckett/TEFRE;
Georgia Healthy
Families
Medical
Assistance
Program;
HealthChoice;
REM Program

Peach Care
for Kids;
Georgia
Healthy
Families

MD

MN

Medical
Assistance
(MA)

Maryland
Children’s
Health
Program
(MCHP);
HealthChoice
Children’s
Health
Insurance
Program

Children with Special
Needs (HCP); CUHIP –
Colorado Uninsurable
Health Insurance Plan;
CoverColorado;
Colorado Indigent Care
Program (CICP)
Refugee Medical
Assistance; Children
with Special Health Care
Needs; Connecticut
Health Reinsurance
Association (HRA);
Connecticut Insurance
Assistance Program for
AIDS Patients
(CIAPAP); StateAdministered General
Assistance Medical Aid
(SAGA); Family Health
Services Division (BCH)
Children’s Medical
Services (CMS);
Indigent Care Trust Fund
(ICTF)

AIDS Insurance
Assistance Program
(MAIAP); Children’s
Medical Services
(CMS); Primary Adult
Care (PAC)
Minnesota Care;
Minnesota General
Assistance Medical Care
Program (GAMC);
HIV/AIDS Insurance
Continuation Program;
Minnesota Children with
Special Health Care
Needs (MCSHN);
Minnesota
Page 7 of 15

NM

SALUD!

New
MexiKids;
New
MexiTeens

NY

The Partnership
Plan; Medicaid

Child Health
Plus

OR

Oregon Health
Plan (OHP)

Oregon
SCHIP

TN

TennCare

Cover Kids

Comprehensive Health
Association (MCHA)
Insurance Assistance
Program; Children’s
Medical Services
(CMS); New Mexico
Medical Insurance Pool
(NMMIP); New Mexico
Health Insurance
Alliance (NMHIA); New
Mexico State Coverage
Insurance (NMSCI);
State Coverage
Insurance (SCI);
Premium Assistance for
Kids (PAK); UNM Care
Program
Family Health Plus;
FHPlus; Health New
York; Physically
Handicapped Children’s
Program; Children with
Special Health Care
Needs Program
(CSHCN); ADAP Plus
Insurance Continuation
Program (APIC);
CDPHP (a combination
commercial and statebased program); Fidelis
Care
CareAssist; Oregon
Services for Children
with Special Health
Needs; Oregon Medical
Insurance Pool (OMIP);
Family Health Insurance
Assistance Program
(FHIAP); Insurance
Purchasing Cooperative;
Children Development
and Rehabilitation
Center
Children’s Special
Services (CSS);
CoverTN; Access TN

Private insurance: patient receives and pays for medical care as part of
Page 8 of 15

a private or managed care system.
Includes commercial carriers (e.g., Blue Cross), fee-for-service and
managed care (HMOs, PPOs,) flexible spending accounts (FSAs),
Health/Medical Savings Accounts (HSAs), and Health Reimbursement
Accounts (HRAs). Excludes plans that pay for only one type of service;
for example, auto insurance policy medical coverage that pays medical
expenses incurred as a result of an auto accident; such plans should be
classified as Other.
The following are a list of private commercial carriers: (NOTE: list is
from the 2019 ABCs CRF Instructions and is not exhaustive of all
carriers).
AARP, Aetna, Aflac, American Postal Workers Union (APWU) Health
Plan, AmeriChoice (subsidiary of UnitedHealth Group), Anthem, Blue
Cross Blue Shield, CDPHP (also counts as state program in NY state),
Cariten Senior Healthcare, Cigna, Federal Employees Health Benefits
(FEHB), First Choice Health, Government Employees Hospital
Association (GEHA), Health Partners, HealthSprings, HighMark,
Humana & Humana Gold, John Deere Health Care (subsidiary of
UnitedHealth Group), LaborCare (PPO option of Medica), MMSI, MP
Health Plans, Medica (subsidiary of Aetna and UnitedHealth Group),
Mega Life and Health Insurance Company, National Association of
Letter Carriers (NALC) Health Benefit Plan, Patient Choice Healthcare
Inc., Physicians Mutual, PreferredOne, Reliant Standard Life,
BasicMed Plan, SelectCare (PPO option of Medica), Total Longterm
Care for Seniors (Supplemental Healthcare for Seniors), Tower Life,
UMR (subsidiary of UnitedHealth Care), UniCare, United American
Insurance Company, UnitedHealth Group, United American Healthcare
Corporation (UAHC), VHP Community Care
Self-pay: patient pays out of pocket at the time of service. Also, include
patients without insurance coverage in this category. Persons are
considered uninsured if they do not have private health insurance,
Medicare, Medicaid, State Children’s Health Insurance Program
coverage, state-sponsored or other government-sponsored health plan,
or military health-care plan. Social services assessments in the medical
record may have information pertaining to uninsured status.
No charge: patient (and/or insurance company) was not billed for
medical services. This is uncommon.
Other: health insurance or health care coverage that does not meet one
of the above categories (e.g., Tricare for active duty military, other
military/retired military healthcare, Indian Health Service, Prisoner
Healthcare Services Correctional Healthcare or other prisoner
healthcare coverage, Ryan White, plans paying specifically for one type
of service).
Page 9 of 15

Unknown: patient’s health insurance is unable to be determined from
information present in the medical record.
Section III.
Weight and height
Sources of weight and height documentation include medication administration or other
pharmacy records, vital signs flow sheets, and admission and progress notes
Weight
Required. Enter the weight of the patient as noted in the medical
record in pounds and ounces or in kilograms.
Example: 158 lbs 0 oz. or 71.6 kilograms
Infants in neonatal locations:
For infants (less than 12 months of age) in neonatal locations only
(defined as locations coded as CC-NURS, CCS-NURS, S-NURS, WNURS, W-LDRP), record the birthweight in pounds and ounces or in
kilograms. Example: 10 lbs 3 oz
If the birthweight cannot be located in the medical record, check
Unknown.
All other patients:
Use weight data recorded on the survey date whenever possible. If no
weight information is available on the survey date, use weight recorded
closest in time in the days before the survey date (going as far back as
the admission date if necessary). For example, if the patient is surveyed
on August 10, and the patient’s weight was 160 lbs on August 1, 158
lbs on August 7, and 155 lbs on August 11, you will report 158 lbs as
the patient’s weight since August 7 is the closest date to the survey date
that is before the survey date.

Height

If there is no weight information available on the survey date or on days
prior to the survey date, check Unknown.
Required. Enter the height of the patient as noted in the medical record
in feet and inches or in centimeters.
Example: 5 ft 2 in or 157 cm
Use height data recorded on the survey date whenever possible. If no
height information is available on the survey date, use height recorded
closest in time in the days before the survey date (going as far back as
the admission date if necessary). Follow the same rule as for weight.

BMI (record only if height
or weight unavailable)

If there is no height information available on the survey date or on days
prior to the survey date, check Unknown.
Required. For patients who are 12 months of age and older, regardless
of hospital location, enter the Body Mass Index (BMI) recorded on the
day of the survey if Weight or Height are Unknown.
If both Weight and Height are available, check NA. For patients who
are less than 12 months of age, also check NA.
Page 10 of 15

If there was no BMI recorded on the survey date, enter the BMI
recorded closest in time in the days before the survey date (going as far
back as the admission date if necessary). Follow the same rule as for
weight and height.
If there is no BMI recorded on the survey date or on days prior to the
survey date, check Unknown.
Section IV.
Devices and pressure injuries/ulcers present on the survey date
Information on devices (urinary catheters, ventilators and central lines) and pressure
injuries/ulcers may be found in nursing notes and patients’ daily flow sheets (e.g., sheets that
include information on vital signs, fluid balance, nursing assessments, operating room flow
sheets, etc.). Progress notes and procedure notes may also contain the information.
Ventilator information may be found in respiratory therapy notes and in intensive care unit
flow sheets in sections documenting the patient’s respiratory status.
Some record systems (particularly electronic record systems) may have a specific location where
information on the presence and status of medical devices is recorded.
There is no minimum duration the device must have been in place; however, it must be in place
on the survey date.
Urinary catheter
Required. Check Yes if the patient has an indwelling urinary catheter
(also called a Foley catheter) in place on the survey date. If a urinary
catheter is not in place on the survey date, check No. Also, check No for
patients who receive intermittent catheterization or “straight”
catheterization and No for patients with nephrostomy tubes or
suprapubic catheters.
Check Unknown only if portions of the medical record are missing and
this information cannot be ascertained (this should be uncommon).
A urinary catheter is defined as: “A drainage tube that is inserted into
the urinary bladder through the urethra, is left in place, and is connected
to a closed collection system; also called a Foley catheter.”

Ventilator

NOTE: This does not include straight in-and-out catheters, suprapubic
catheters, or nephrostomy tubes.
Required. Check Yes if the patient has a device to assist or control
respiration through a tracheostomy or by endotracheal intubation that is
in place on the survey date. If a ventilator is not in place on the survey
date, check No.
Check Unknown only if portions of the medical record are missing and
this information cannot be ascertained (this should be uncommon).
A ventilator is defined as “A device to assist or control respiration,
inclusive of the weaning period, through a tracheostomy or by
endotracheal intubation.”
NOTE: Lung expansion devices such as intermittent positive pressure
Page 11 of 15

Central line

breathing (IPPB); nasal positive end- expiratory pressure (PEEP);
continuous nasal positive airway pressure (CPAP, hypoCPAP) are not
considered ventilators unless delivered via tracheostomy or
endotracheal intubation (e.g., ET-CPAP).
Required. Check Yes if the patient has a central line in place on the
survey date and answer the sub-question.
If a central line is not in place on the survey date, check No and proceed
to pressure injuries/ulcers.
Check Unknown only if portions of the medical record are missing and
this information cannot be ascertained (this should be uncommon).
A central line is defined as: “An intravascular catheter that terminates at
or close to the heart or in one of the great vessels which is used for
infusion, withdrawal of blood, or hemodynamic monitoring. The
following are considered great vessels for the purpose of reporting
central-line infections: aorta, pulmonary artery, superior vena cava,
inferior vena cava, brachiocephalic veins, internal jugular veins,
subclavian veins, external iliac veins, common iliac veins, and femoral
veins.”
NOTE:
• Neither the insertion site nor the type of device may be used to
determine if a line qualifies as a central line. The device must
terminate in one of these vessels or in or near the heart, and be
used for one of the purposes outlined above, to qualify as a
central line.
• At times, an intravascular line may migrate from its original
great vessel location. Subsequent to the original confirmation,
ongoing confirmation that a line resides in a great vessel is not
required. Therefore, once a line is identified to be a central line,
it is considered a central line until discontinuation, regardless of
migration.
• An introducer is considered an intravascular catheter, and
depending on the location of its tip and use, may be a central
line.
• Pacemaker wires and other nonlumened devices inserted into
central blood vessels or the heart are not considered central
lines, because fluids are not infused, pushed, nor withdrawn
through such devices.
• In neonates, the umbilical artery/vein is considered a great
vessel.
• The following devices are not considered central lines:
extracorporeal membrane oxygenation (ECMO), femoral
arterial catheters, intraaortic balloon pump (IABP) devices, and
hemodialysis reliable outflow (HeRO) dialysis catheters.
Page 12 of 15

If “Yes,” (i.e.,
central line in
place on survey
date) indicate how
many lines

Pressure injuries or ulcers

If “Yes,” (i.e.,
pressure injuries
or ulcers present
on survey date),
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

If you checked Yes to the previous question (i.e., central line in place on
the survey date), you are Required to check the number of lines in
place.
If you are unable to determine the number of lines in place, check
Unknown.
NOTE: Indicate the number of individual central lines, NOT the
number of lumens. For example, if the patient has one double-lumen
central line in place, you should check the box to indicate that the
patient has 1 central line.
Required. Check Yes if the patient has documentation of pressure
injuries or ulcers present on the survey date and answer the subquestions. If a pressure injury or ulcer is not present on the survey date,
check No and proceed to Section V.
Check Unknown only if portions of the medical record are missing and
this information cannot be ascertained (this should be uncommon).
If you checked Yes to the previous question (i.e., pressure injuries or
ulcers present on the survey date), you are Required to check if all
pressure injuries or ulcers were present on admission.
This information may be found in the admission notes for the patient.
Check Yes if there is documentation of any of the pressure injuries or
ulcers being present on admission. If all injuries or ulcers developed in
the hospital, check No and proceed to the next sub-question.
Check Unknown only if portions of the medical record (such as the
admission notes) are missing and this information cannot be ascertained
(this should be uncommon).
If pressure injuries or ulcers are present on the survey date, you
are Required to check the highest stage of the injuries or ulcers
according to documentation available in the medical record only.
NOTE: Pressure injury or ulcer definitions are available at:
http://www.npuap.org/resources/educational-and-clinicalresources/npuap-pressure-injury-stages/
However, you are only required to use information available in the
patient’s medical record to answer this question. Do not apply standard
definitions such as those of the National Ulcer Pressure Advisory Panel
or the Center for Medicare and Medicaid Services.
If the patient has more than one pressure ulcer or injury present on the
survey date, report the highest stage. For example, the patient has a
Stage 3 pressure ulcer on his sacrum and a Stage 2 pressure ulcer on his
right heel, check Stage 3 on the form.

Page 13 of 15

Check Unstageable if “deep tissue pressure injury” is the only stage
documented in the patient’s medical record.
If there is no documentation available in the medical record for the
stage of the pressure injury or ulcer, check Unknown.
Section V.
Antimicrobials
Use the paper or electronic Medication Administration Record (MAR) (including the
Emergency Department MAR and the inpatient MAR) and operating room flow sheets (on
which surgical prophylaxis antibiotics may be recorded) to determine whether patients are
being administered or are scheduled to be administered antimicrobials.
Antimicrobials administered or scheduled to be administered: (Answer both questions)
On the survey
Required. Check Yes if the patient was administered at least one dose
date
of an antimicrobial drug on the survey date. Otherwise, check No.
Acceptable antimicrobials are those that appear in Appendix 3 of the
Operational Manual that are administered by any of the following
routes: IV, IM, orally, enterally, or via inhalation.
Check Unknown only if portions of the medical record are missing and
this information cannot be ascertained (this should be uncommon).
NOTE: check Yes if you see that the patient was getting an
antimicrobial drug or was scheduled to receive an antimicrobial drug at
some time on the calendar day (midnight-11:59 p.m.) before the survey
date or on the calendar day of the survey date—even if the patient is not
scheduled to get the drug until later on the survey date.

On the day before
the survey date

For example, if you are reviewing a patient record at 11 a.m. on the
survey date and you see the patient is scheduled to receive an
antimicrobial drug at 10 p.m. on the survey date, you will check Yes.
This could be more of a challenge if you are reviewing a record
retrospectively. In that case, you are reviewing the record and entering
data according to information present in the record up to 5 pm on the
survey date. If there is information present in the record at 4 p.m. on the
survey date indicating that the patient was scheduled to receive an
antimicrobial drug starting at 9 p.m. that evening (on the survey date),
you will check Yes.
Required. Check Yes if the patient was scheduled to be administered at
least one dose of an antimicrobial drug on the day before the survey
date. Otherwise, check No.
Acceptable antimicrobials are those that appear in Appendix 3 of the
Operational Manual that are administered by any of the following
routes: IV, IM, orally, enterally, or via inhalation.
Check Unknown only if portions of the medical record are missing and
this information cannot be ascertained (this should be uncommon).
Page 14 of 15

Section VI.

NOTE: Refer to the guidance for antimicrobials administered or
scheduled to be administered on the survey date.
Follow-up information

In many instances, EIP Teams will collect this information. Check with your EIP Team Project
Coordinator to determine if/when the Hospital Staff will complete this section of the form.
Data collectors should attempt to ascertain hospital discharge date and patient outcome at the
time of discharge for all patients included in the survey, unless 6 months has elapsed since the
survey date and the patient is still in the hospital (same hospitalization that includes the survey
date). Once 6 months have passed since the survey date, attempts to collect discharge and
outcome information may stop.
Enter date of follow-up
Required. Enter the numeric follow-up date for the patient in the
data collection
following format:
MM/DD/YYYY.
Example: Example: 06/01/2020
Hospital discharge date
Required. Enter the numeric discharge date for the patient in the
MM/DD/YYYY format if available.
Example 05/28/2020
If the patient is still in the hospital at the time of follow-up, and 6
months have passed since the survey date, check Still in hospital.
If 6 months have not passed since the survey date, wait until 6 months
have passed before completing the follow-up information section for
the patient.

Patient outcome at time of
hospital discharge

If the patient was discharged, but the specific discharge date is
unavailable, check Unknown.
Required. Check patient outcome at the time of discharge to indicate if
the patient Survived or Died.
If the patient is still in the hospital at the time of follow-up, and 6
months have passed since the survey date, check Still in hospital.
If 6 months have not passed since the survey date, wait until 6 months
have passed before completing the follow-up information section for
the patient.
If the patient was discharged, but the outcome at time of discharge is
unavailable, check Unknown.
The Patient Information Form is complete.

Page 15 of 15