Form Cdc 57 128 – Fill Out and Use This PDF

Form Approved

OMB No. 0920-0666

Exp. Date: 10/31/2016

www.cdc.gov/nhsn

Laboratory-identified MDRO or CDI Event

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*required for saving

Facility ID:					Event #:
*Patient ID:					Social Security #:
Secondary ID:					Medicare #:
Patient Name, Last:				First:				Middle:
*Gender: M	F				*Date of Birth:
Ethnicity (Specify):					Race (Specify):
Event Details
*Event Type: LabID					*Date Specimen Collected:
*Specific Organism Type: (Check one)					□ VRE			□ C. DIFFICILE
□ MRSA		□ MSSA
□ CephR-KLEBSIELLA		□ CRE-E. COLI			□ CRE-KLEBSIELLA			□ MDR-ACINETOBACTER
*Outpatient:	Yes No			*Specimen Body Site/System:				*Specimen Source:
*Date Admitted to Facility:				*Location:				*Date Admitted to Location:
*Has patient been discharged from your facility in the past 3 months? Yes								No
If Yes, date of last discharge from your facility:
Custom Fields
Label						Label
______________________				____/____/____		_______________________			____/____/_____
_______________________				_____________		_______________________			______________
_______________________				_____________		_______________________			______________
_________________________				______________		_______________________			______________
_________________________				______________		_______________________			______________
_________________________				______________		_______________________			______________
_________________________				______________		_______________________			______________

Comments

Assurance of Confidentiality: The voluntarily provided information obtained in this surveillance system that would permit identification of any individual or institution is collected with a guarantee that it will be held in strict confidence, will be used only for the purposes stated, and will not otherwise be disclosed or released without the consent of the individual, or the institution in accordance with Sections 304, 306 and 308(d) of the Public Health Service Act (42 USC 242b, 242k, and 242m(d)).

Public reporting burden of this collection of information is estimated to average 15 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 OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC, Reports Clearance Officer, 1600 Clifton Rd., MS D-74, Atlanta, GA 30333, ATTN: PRA (0920-0666).

CDC 57.128 Rev5, v6.6