Record relates to: Facility Name Patients/Residents Facility designation and unit Staff Date Reported No. of Staff on Unit (yyyy-Mon-dd) Outbreak Number Phone Number No. of Patients/Residents in Unit Unit Name/No. Fax Number Phone Fax Outbreak Response Lead Demographics Case 1 Case 2 Case 3 Case 4 Case 5 Last Name First Name Gender ULI Date of Birth (yyyy-Mon-dd) Room Number Admission Date (yyyy-Mon-dd) Symptom Legend Onset Date (yyyy-Mon-dd) (yyyy-Mon-dd) (yyyy-Mon-dd) (yyyy-Mon-dd) (yyyy-Mon-dd) AP Abdominal Symptoms Pain D Diarrhea Date Contact E Exhaustion Precautions Were F Fever Implemented DE Deceased Date Hospitalized HO Hospitalized (if within previous 4 weeks) N Nausea Date of Discharge V Vomiting (yyyy-Mon-dd) Name of Hospital Risk Factors and Unit ABX Antibiotics Risk Factors For PPI Proton pump Infection inhibitor GI Recent gastrointestinal Comments surgery. Date Stool Specimen (yyyy-Mon-dd) (yyyy-Mon-dd) (yyyy-Mon-dd) (yyyy-Mon-dd) (yyyy-Mon-dd) Lab Tests Collected for CDI Results Treatment Information Treatment Medications (Terminal clean completed in conjunction with personal hygiene). Date Precautions (yyyy-Mon-dd) (yyyy-Mon-dd) (yyyy-Mon-dd) (yyyy-Mon-dd) (yyyy-Mon-dd) Discontinued. 20649(2016-11)
Facility Name Record relates to: Patients/Residents Staff Outbreak Number Facility designation and unit Date Reported (yyyy-Mon-dd) No. of Staff on Unit Phone Number No. of Patients/Residents in Unit Fax Number Unit Name/No. Outbreak Response Lead Phone Fax Demographics Case 1 Case 2 Case 3 Case 4 Case 5 Last Name First Name Gender ULI Date of Birth (yyyy-Mon-dd) Room Number Admission Date (yyyy-Mon-dd) Symptom Legend AP Abdominal Pain D Diarrhea E Exhaustion F Fever DE Deceased HO Hospitalized N Nausea V Vomiting Risk Factors ABX Antibiotics PPI Proton pump inhibitor GI Recent gastrointestinal surgery. Onset Date (yyyy-Mon-dd) (yyyy-Mon-dd) (yyyy-Mon-dd) (yyyy-Mon-dd) (yyyy-Mon-dd) Symptoms Date Contact Precautions Were Implemented Date Hospitalized (if within previous 4 weeks) Date of Discharge (yyyy-Mon-dd) Name of Hospital and Unit Risk Factors For Infection Comments Lab Tests Date Stool Specimen Collected for CDI (yyyy-Mon-dd) (yyyy-Mon-dd) (yyyy-Mon-dd) (yyyy-Mon-dd) (yyyy-Mon-dd) Results Treatment (Terminal clean completed in conjunction with personal hygiene). Treatment Information Medications Date Precautions Discontinued. (yyyy-Mon-dd) (yyyy-Mon-dd) (yyyy-Mon-dd) (yyyy-Mon-dd) (yyyy-Mon-dd) 20649(2016-11)
frm-20694.docx