Invasive Methicillin-Resistant-Staphylococcus Aureus Active Bacterial Core Surveillance (Abcs) Case Report Form

Patient ID: _____ _____ _____ _____ _____ _____ _____ _____

– ACTIVE BACTERIAL CORE SURVEILLANCE CASE REPORT –

Phone No.: (

)

Patient's Name:

(Last, First, M.I.)

Patient

Address:

Chart No

(Number, Street, Apt. No.)

Hospital:

(City, State)

(Zip Code)

– Patient identifier information is NOT transmitted to CDC –

DEPARTMENT OF

INVASIVE METHICILLIN-RESISTANT • STAPHYLOCOCCUS AUREUS

HEALTH & HUMAN SERVICES

CENTERS FOR DISEASE CONTROL

CTIVE

ACTERIAL

ORE SURVEILLANCE (ABCs) CASE REPORT – 2015

AND PREVENTION

ATLANTA, GA 30329

– SHADED AREAS BELOW INDICATE CORE VARIABLES –

Form Approved OMB No. 0920-0978

1. STATE:

2. COUNTY:

3. STATE I.D.:

4a. HOSPITAL/LAB I.D. WHERE

4b. HOSPITAL I.D. WHERE PATIENT TREATED:

(Residence of patient)

(Residence of Patient)

CULTURE IDENTIFIED:

6. DATE OF BIRTH:

5. SEX:

8. STERILE SITE(S) FROM WHICH MRSA WAS INITIALLY

7a. AGE:

ISOLATED: (Check all that apply)

ale

Blood

Pericardial fluid

Internal body site (specify)

Mo.

Day

Year

Female

_____________________

CSF

Joint/Synovial fluid

7b. Is age in day/mo/yr?

Bone

Pleural fluid

Other sterile site (specify)

Peritoneal fluid

Muscle

Days 2

Mos. 3

Yrs.

______________________

9. DATE OF INITIAL CULTURE:

10. WAS THE PATIENT HOSPITALIZED AT THE TIME OF,

11. WAS CULTURE COLLECTED >3 CALENDAR DAYS

OR WITHIN 30 CALENDAR DAYS AFTER, INITIAL CULTURE?

AFTER HOSPITAL ADMISSION?

Mo.

Day

Year

Yes (HO-MRSA case) 2

No (Complete CRF, CA-MRSA or HACO-MRSA case)

Yes

Unknown

If YES: Date of admission

If yes, was the case selected for full CRF based on

Mo.

Day

Year

sampling frame 1:10?

Yes (Complete CRF)

No (STOP data abstraction)

12a. ETHNIC ORIGIN:

12c. WEIGHT:

13. At time of first positive

15. Where was the patient located on the

Unknown

culture, patient was:

4th calendar day prior to the date of initial culture?

Hispanic

or Latino

_______

lbs

_______

oz OR

_______

Pregnant

Private Residence

Not Hispanic

or Latino

Long Term Care Facility

Post-partum

12d. HEIGHT:

Unknown

Long Term Acute Care Hospital

Neither

Homeless

12b. RACE:

_______

_______ in OR

_______

(Check all that apply)

Unknown

Incarcerated

White

12e. BMI:

Hospital Inpatient

Black or

Unknown

14. If case is 12 months of age,

African American

type of birth hospitalization:

Other

__________________________

American Indian

_______

(do not calculate, only if available in the MR)

NICU/SCN

or Alaska Native

Unknown

Asian

Well Baby Nursery

Native Hawaiian

Unknown

or Other Pacific Islander

Unknown

16. LOCATION OF CULTURE COLLECTION: (Check one)

17. Were cultures of the SAME or OTHER sterile site(s) positive within 30 days after initial culture date?

Hospital Inpatient

Outpatient

Yes

Unknown

LTCF

Clinic/

ICU

LTACH

If yes, indicate site and date of last positive culture:

Doctors Office

Internal body site

Surgery/OR

Autopsy

Surgery

Blood, Date:

________

Date:

________

Pericardial fluid , Date:

________

Radiology

Unknown

Dialysis/Renal Clinic

Other sterile site

Joint/Synovial fluid, Date:

CSF , Date:

________

Other Unit

Other

(specify)

____________

Bone , Date:

________

Pleural fluid , Date:

________

Outpatient

Date:

________

Emergency Room

Peritoneal fluid, Date:

________

Muscle, Date:

______

Observational Unit/Clinical Decision Unit

18. PATIENT OUTCOME:

Unknown

Survived

Died

Mo.

Day

Year

Mo.

Day

Year

Date of death

Date of discharge

Was MRSA cultured from a normally sterile site < calendar day 7 before death?

Yes 2

If survived, was the patient transferred to a LTCF?

Yes 2

No 9

Unknown

If survived, was the patient transferred to a LTACH?

Yes 2

Public reporting burden of this collection of information is estimated to average 10 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 OMBcontrol 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 Reports Clearance Officer; 1600 Clifton Road NE, MS E-11, Atlanta, Georgia 30329; ATTN: PRA (0920-0978)

Page 1 of 2

–

IMPORTANT – PLEASE COMPLETE THE BACK OF THIS FORM

–