Non-Substantive Change Request Crosswalk 15DEC2021

Cross walk - 2022 form changes

HAIC

1. HAIC: Multi-site Gram-Negative Surveillance Initiative (MuGSI-CRE/CRAB) (Attachment #3)

Note: Change for the updated 2022 CRF are highlighted in yellow.

Question on 2021 form

Question on 2022 form

Patient identifier information

Patient’s name:			Phone no.:
Address:			MRN:
City:	State:	Zip code:		Hospital:

Patient identifier information

Patient’s name:	Phone no.:
Address:	MRN:
Address type:		Hospital:

23c. Chest radiology findings (check all that apply

 Not done

 No report available

 Acute respiratory distress syndrome (ARDS)

 Air space density/opacity

 Ground glass opacities/infiltrates

 Bronchopneumonia/pneumonia

 Cannot rule out pneumonia

 Cavitation

 Consolidation

 Infiltrate

 Pleural effusion

 Nodules

23c. Chest radiology findings (check all that apply

 Not done

 No report available

 Acute respiratory distress syndrome (ARDS)

 Air space density/opacity

 Ground glass opacities/infiltrates

 Bronchopneumonia/pneumonia

 Cannot rule out pneumonia

 Cavitation

 Consolidation

 Infiltrate

 Pleural effusion

 Nodules

 No evidence of pneumonia

24a. Did the patient have a positive test(s) for SARS-CoV-2 (molecular assay, serology, or other confirmatory test) on or before the DISC?

 Yes

 No

 Unknown

24a. Did the patient have a positive test(s) for SARS-CoV-2 (molecular assay, serology, or other confirmatory test) in the year before or day of the DISC?

 Yes

 No

 Unknown

24b. If yes, complete table below:

	Specimen collection date	Test type
FIRST positive test for SARS-Cov-2 on or before the DISC:	__/__/____ □ Unknown	□ Molecular assay □ Antigen □ Serology □ Unknown □ Other (specify):___________
MOST RECENT positive test for SARS-Cov-2 on or before the DISC:	__/__/____ □ Unknown	□ Molecular assay □ Antigen □ Serology □ Unknown □ Other (specify):___________

24b. If yes, complete the table below for the most recent positive SARS-CoV-2 test in the year before or day of the DISC:

Specimen collection date	Test type
__/__/____ □ Unknown	□ Molecular assay □ Antigen □ Serology □ Unknown □ Other (specify):___________

29b. CRF Status

 Complete

 Pending

 Chart unavailable after 3 requests

29b. CRF Status

 Complete

 Pending

 Chart unavailable after 3 requests

 Complete – Pending Data

2. HAIC: Multi-site Gram-Negative Surveillance Initiative ─ Extended-Spectrum Beta-Lactamase-Producing Enterobacteriaceae (MuGSI-ESBL) (Attachment #4)

Note: Change for the updated 2022 CRF are highlighted in yellow.

Question on 2021 form 

Question on 2022 form  

Patient identifier information 

 

Patient’s name:			Phone no.:
Address:			MRN:
City:	State:	Zip code:		Hospital:

 

Patient identifier information 

 

Patient’s name:	Phone no.:
Address:	MRN:
Address type:		Hospital:

 

 

24b. IF YES, CHECK ALL ANTIMICROBIALS USED IN THE 30 DAYS BEFORE THE DISC: (Check all that apply) □ Unknown 

 

□ Amikacin 

□ Amoxicillin 

□  Amoxicillin/clavulanic acid 

□  Ampicillin 

□  Ampicillin/sulbactam 

□  Azithromycin 

□  Aztreonam 

□  Cefazolin 

□  Cefdinir 

□  Cefepime 

□  Cefiderocol 

□  Cefixime 

□  Cefotaxime 

□  Cefoxitin 

□  Cefpodoxime 

□  Ceftaroline 

□ Ceftazidime 

□ Ceftazidime/avibactam 

□ Ceftizoxime 

□ Ceftolozane/tazobactam 

□ Ceftriaxone 

□ Cefuroxime 

□ Cephalexin 

□ Ciprofloxacin 

□ Clarithromycin 

□ Clindamycin 

□ Dalbavancin 

□ Daptomycin 

□ Delafloxacin 

□ Doripenem 

□  Doxycycline 

□  Eravacycline 

□  Ertapenem 

□  Fidaxomicin 

□  Fosfomycin 

□  Gentamicin 

□  Imipenem/cilastatin 

□  Levofloxacin 

□  Linezolid 

□  Meropenem 

□  Meropenem/ 

vaborbactam 

□  Metronidazole 

□  Moxifloxacin 

□  Nitrofurantoin 

□  Omadacycline 

□  Oritavancin 

□  Penicillin 

□  Piperacillin/tazobactam 

□  Polymyxin B 

□  Polymyxin E (colistin) 

□  Rifaximin 

□  Tedizolid 

□  Telavancin 

□  Tigecycline 

□  Tobramycin 

□  Trimethoprim 

□  Trimethoprim/ 

sulfamethoxazole 

□  Vancomycin 

    □  IV 

    □  PO 

□  Other (specify): _____________________ 

□  Other (specify): _____________________ 

 

24b. IF YES, CHECK ALL ANTIMICROBIALS USED IN THE 30 DAYS BEFORE THE DISC: (Check all that apply) □ Unknown 

 

□ Amikacin 

□ Amoxicillin 

□  Amoxicillin/clavulanic acid 

□  Ampicillin 

□  Ampicillin/sulbactam 

□  Azithromycin 

□  Aztreonam 

□  Cefadroxil 

□  Cefazolin 

□  Cefdinir 

□  Cefepime 

□  Cefiderocol 

□  Cefixime 

□  Cefotaxime 

□  Cefoxitin 

□  Cefpodoxime 

□  Ceftaroline 

□ Ceftazidime 

□ Ceftazidime/avibactam 

□ Ceftizoxime 

□ Ceftolozane/tazobactam 

□ Ceftriaxone 

□ Cefuroxime 

□ Cephalexin 

□ Ciprofloxacin 

□ Clarithromycin 

□ Clindamycin 

□ Dalbavancin 

□ Daptomycin 

□ Delafloxacin 

□ Doripenem 

□  Doxycycline 

□  Eravacycline 

□  Ertapenem 

□  Fidaxomicin 

□  Fosfomycin 

□  Gentamicin 

□  Imipenem/cilastatin 

□  Levofloxacin 

□  Linezolid 

□  Meropenem 

□  Meropenem/ 

vaborbactam 

□  Metronidazole 

□  Moxifloxacin 

□  Nitrofurantoin 

□  Omadacycline 

□  Oritavancin 

□  Penicillin 

□  Piperacillin/tazobactam 

□  Polymyxin B 

□  Polymyxin E (colistin) 

□  Rifaximin 

□  Tedizolid 

□  Telavancin 

□  Tigecycline 

□  Tobramycin 

□  Trimethoprim 

□  Trimethoprim/ 

sulfamethoxazole 

□  Vancomycin 

    □  IV 

    □  PO 

□  Other (specify): _____________________ 

□  Other (specify): _____________________ 

25a. Did the patient have a positive test(s) for SARS-CoV-2 (molecular assay, serology, or other confirmatory test) on or before the DISC? 

ð Yes 

ð No  

ð Unknown 

25a. Did the patient have a positive test(s) for SARS-CoV-2 (molecular assay, serology, or other confirmatory test) in the year before or day of the DISC? 

ð Yes 

ð No  

ð Unknown 

25b. If yes, complete table below: 

 

	Specimen collection date	Test type
FIRST positive test for SARS-Cov-2 on or before the DISC:	__/__/____  □ Unknown	□ Molecular assay  □ Antigen  □ Serology  □ Unknown  □ Other (specify):___________
MOST RECENT positive test for SARS-Cov-2 on or before the DISC:	__/__/____  □ Unknown	□ Molecular assay  □ Antigen  □ Serology  □ Unknown  □ Other (specify):___________

 

25b. If yes, complete the table below for the most recent positive SARS-CoV-2 test in the year before or day of the DISC: 

 

Specimen collection date	Test type
__/__/____  □ Unknown	□ Molecular assay  □ Antigen  □ Serology  □ Unknown  □ Other (specify):___________

 

28b. CRF STATUS: 

ð Complete 

ð Complete-Pending 

ð Pending 

ð Chart unavailable after 3 requests 

 

 

28b. CRF STATUS: 

ð Complete 

ð Complete-Pending 

ð Pending 

ð Chart unavailable after 3 requests