Inter-Facility Infection Control Transfer Form - Cdc Page 2
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2Inter-facility Infection Control Transfer Form
This form must be filled out for transfer to accepting facility with information communicated prior to or with transfer
Please attach copies of latest culture reports with susceptibilities if available
Sending Healthcare Facility:
Patient/Resident Last Name
First Name
Date of Birth
Medical Record Number
___/____/_______
Name/Address of Sending Facility
Sending Unit
Sending Facility phone
Sending Facility Contacts
NAME
PHONE
E-mail
Case Manager/Admin/SW
Infection Prevention
Is the patient currently in isolation?
□ NO
□ YES
Type of Isolation (check all that apply) □ Contact □ Droplet □ Airborne □ Other:
_________________
Does patient currently have an infection, colonization OR a history of positive culture of
Colonization
Active infection
a multidrug-resistant organism (MDRO) or other organism of epidemiological
or history
on Treatment
significance?
Check if YES
Check if YES
Methicillin-resistant Staphylococcus aureus (MRSA)
Vancomycin-resistant Enterococcus (VRE)
Clostridium difficile
Acinetobacter, multidrug-resistant*
E coli, Klebsiella, Proteus etc. w/Extended Spectrum Β-Lactamase (ESBL)*
Carbapenemase resistant Enterobacteriaceae (CRE)*
Other:
Does the patient/resident currently have any of the following?
Cough or requires suctioning
Central line/PICC (Approx. date inserted ___/___/_____)
Diarrhea
Hemodialysis catheter
Vomiting
Urinary catheter (Approx. date inserted ___/___/_____)
Incontinent of urine or stool
Suprapubic catheter
Open wounds or wounds requiring dressing change
Percutaneous gastrostomy tube
Drainage (source)____________________________
Tracheostomy
Is the patient/resident currently on antibiotics? □ NO □ YES:
Antibiotic and dose
Treatment for:
Start date
Anticipated stop date
Vaccine
Date administered (If
Lot and Brand (If
Year administered
Does Patient self report
known)
known)
(If exact date not
receiving vaccine?
known)
Influenza (seasonal)
yes
no
o
o
Pneumococcal
yes
no
o
o
Other:_____________
yes
no
o
o
Printed Name of Person
Signature
Date
If information communicated prior to transfer: Name and
completing form
phone of individual at receiving facility
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