Form
Approved
OMB No. 0935-XXXX
Exp. Date XX/XX/20XX
AHRQ Safety Program for MRSA Prevention
Clinical Outcomes Data for Surgical Services
This will be an online data reporting form.
Causative organisms – monthly
Month, Year |
Surgical Service (Selected from below)
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Type of surgical procedure (Choices dependent on Setting)
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Count of SSIs by each causative organism |
Organism – selected from dropdown menu (See List of Organisms, page 3) |
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Public
reporting burden for this collection of information is estimated to
average 30 minutes per response, the estimated time required to
complete the survey. 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, AHRQ Reports Clearance Officer, Attention: PRA,
Paperwork Reduction Project (0935-0143), AHRQ, 5600 Fishers Lane, MS
0741A, Rockville, MD 20857
The
confidentiality of your responses is protected by Sections 944(c)
and 308(d) of the Public Health Service Act [42 U.S.C. 299c-3(c) and
42 U.S.C. 242m(d)]. Information that could identify you will not be
disclosed unless you have consented to that disclosure.
Month, Year |
Surgical Service (Selected from below)
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Type of surgical procedure (Choices dependent on Setting)
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Count of surgical procedures performed in the given period |
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Staphylococcus aureus |
Methicillin-resistant (MRSA) |
Methicillin-susceptible (MSSA) |
Coagulase-Negative Staphylococcus |
Candida |
Candida albicans |
Candida glabrata |
Candida parapsilosis |
Candida tropicalis |
Candida krusei |
Candida lusitaniae |
Candida sp.(unspeciated) |
Enterococcus |
Enterococcus faecalis |
Enterococcus faecium |
Enterococcus sp. |
Klebsiella |
Klebsiella pneumoniae |
Klebsiella oxytoca |
Escherichia coli |
Enterobacter |
Enterobacter cloacae |
Enterobacter aerogenes |
Enterobacter agglomerans |
Enterobacter sp. |
Pseudomonas |
Pseudomonas aeruginosa |
Pseudomonas sp. |
Streptococcus |
Streptococcus viridans grp |
Streptococcus, Group B |
Streptococcus pneumoniae |
Streptococcus, Group A |
Streptococcus, Group C |
Streptococcus anginosis grp |
Streptococcus, Group F |
Streptococcus, Group G |
Acinetobacter |
Acinetobacter baumannii |
Acinetobacter lwoffii |
Serratia |
Serratia marcescens |
Serratia sp. |
Bacteroides |
Bacteroides fragilis |
Bacteroides, other sp. |
Proteus mirabilis |
Stenotrophomonas maltophilia |
Clostridium |
Citrobacter |
Citrobacter freundii |
Citrobacter koseri |
Morganella morganii |
Achromobacter sp. |
Providencia stuartii |
Alcaligenes xylosoxidans |
Pantoea agglomerans |
Other |
File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
Author | Samuel Kim |
File Modified | 0000-00-00 |
File Created | 2022-10-20 |