Form assigned ABC

– ACTIVE BACTERIAL CORE SURVEILLANCE CASE REPORT –

Phone No.: (
Patient
Chart No.:

Patient's Name:
(Last, First, M.I.)

Address:

)

(Number, Street, Apt. No.)

Hospital:

(Zip Code)

(City, State)

– Patient identifier information is not transmitted to CDC –
DEPARTMENT OF
HEALTH & HUMAN SERVICES
CENTERS FOR DISEASE CONTROL
AND PREVENTION
ATLANTA, GA 30333

ACTIVE BACTERIAL CORE
SURVEILLANCE (ABCs) CASE REPORT
A CORE COMPONENT OF THE EMERGING INFECTIONS PROGRAM NETWORK
OMB No. 0920-0009

– SHADED AREAS FOR OFFICE USE ONLY –

1. STATE:
(Residence
of Patient)

5. WAS PATIENT
HOSPITALIZED?

If YES, date of admission:
Mo.

1

3. STATE I.D.:

2. COUNTY:
(Residence of Patient)

Yes

2

Day

Date of discharge:

Year

Mo.

Yes 2

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

6a. Was patient transferred
from another hospital?

6b. If YES, hospital I.D.

Year

1

No

7a. Was patient a resident of a nursing home or other
chronic care facility at the time of first positive culture?
1

Day

4a. HOSPITAL /LAB I.D. WHERE
CULTURE IDENTIFIED:

No 9

Yes 2

Mo.

Unk

9b. Is age in day/mo/yr?

9a. AGE:

8. DATE OF BIRTH:

Unk

No 9

Day

Year

1

Days 2

Mos. 3

Yrs.

7b. If yes, name _____________________________________
10. SEX:

11a. ETHNIC ORIGIN:

1

Male

2

Female

1

Hispanic or Latino

2

Non-Hispanic or Latino

9

Unk

11b. RACE: (Check all that apply)

12a. WEIGHT:

1

White

1

Asian

________ lbs ________ oz OR ________ kg

1

Black

1

12b. HEIGHT:

1

American Indian/ 1
Alaskan Native

Native Hawaiian/
Pacific Islander
Unk

________ ft ________ in OR ________ cm

13. TYPE OF INSURANCE: (check all that apply)
1

Medicare

1

Indian Health Service (IHS)

1

No health care coverage

Military/VA

1

Private/HMO/PPO/managed care plan

1

Unk

Medicaid/state assistance program

15. Was patient pregnant/post-partum
at time of first positive culture?
1

Yes 2

No 9

1

Survived

2

Died

9

Unk

16. If patient <1 month of age:
If YES, outcome of fetus:
1

Survived, no apparent illness

3

Live birth/neonatal death

5

Induced abortion

2

Survived, clinical infection

4

Abortion/stillbirth

9

Unk

Unk

1

Bacteremia
without Focus

1

Peritonitis

1

Endometritis

1

Meningitis

1

Pericarditis

1

STSS

1

Otitis media

1

Septic abortion

1

Necrotizing fasciitis

1

Pneumonia

1

Chorioamnionitis

1

Puerperal sepsis

1

Cellulitis

1

Septic arthritis

1

Other (specify)

1

Epiglottitis

1

Osteomyelitis

__________________________

1

Hemolytic uremic
syndrome (HUS)
Abscess (not skin)

1

Empyema

__________________________

1

Endocarditis

__________________________

19. STERILE SITES FROM WHICH ORGANISM ISOLATED: (Check all that apply)
1

Blood

1

Peritoneal fluid

1

Bone

1

CSF

1

Pericardial fluid

1

Muscle

Birthweight:

(wks)

(gms)

18a. BACTERIAL SPECIES ISOLATED FROM ANY NORMALLY STERILE SITE:
1

Neisseria meningitidis

4

Listeria monocytogenes

2

Haemophilus influenzae

5

Group A streptococcus

3

Group B streptococcus

6

Streptococcus pneumoniae

18b. OTHER BACTERIAL SPECIES ISOLATED FROM ANY NORMALLY
STERILE SITE: (specify)

20. DATE FIRST POSITIVE
CULTURE OBTAINED:
(Date Specimen Drawn)
Mo.

Joint

Gestational
age:

Day

Year

21. OTHER SITES FROM WHICH ORGANISM
ISOLATED: (Check all that apply)
1

Placenta

1

Middle ear

1

Amniotic fluid

1

Sinus

1

Pleural fluid

1

Internal body site (specify) ________________________________________________________

1

Wound

Other normally sterile site (specify) ___________________________________

1

Other (specify) _________________

1

1

1

Other (specify) ______________________________________________

17. TYPES OF INFECTION CAUSED BY ORGANISM: (Check all that apply)

1

Unk

14. OUTCOME:

1
1

Unk

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 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, Project Clearance Officer, 1600 Clifton Road, MS D-74, Atlanta, GA 30333, ATTN: PRA (0920-0009). Do not send the completed form to this address.
CDC 52.15A

REV. 12-2004

– ACTIVE BACTERIAL CORE SURVEILLANCE CASE REPORT –

– IMPORTANT – PLEASE COMPLETE THE BACK OF THIS FORM –

Page 1 of 2

22. UNDERLYING CAUSES OR PRIOR ILLNESS:
1

Current Smoker

(Check all that apply)

1

Asthma

(If none or chart unavailable, check appropriate box) 1

Multiple Myeloma

1

Emphysema/COPD

1

1

Sickle Cell Anemia

1

1

1

Splenectomy/Asplenia

Systemic Lupus
Erythematosus (SLE)

1

Immunoglobulin Deficiency

1

Diabetes Mellitus

1

1
1

1

Immunosuppressive Therapy
(Steroids, Chemotherapy, Radiation) 1

Nephrotic Syndrome

1

Leukemia

1

HIV Infection

1

Hodgkin's Disease

1

AIDS or CD4 count <200

Renal Failure/Dialysis

Unknown

1

Cochlear Implant

Alcohol Abuse
Atherosclerotic Cardiovascular
Disease (ASCVD)/CAD
Heart Failure/CHF

1

Deaf/Profound Hearing Loss
Other Malignancy (specify)

1

_____________________________________
Organ Transplant (specify)

1

Obesity
CSF Leak
IVDU
Cerebral Vascular Accident (CVA) / Stroke
Complement Deficiency

1
1
1
1

1

Cirrhosis/Liver Failure

1

1

None

_____________________________________
1
Other Prior Illness (specify)
_____________________________________
_____________________________________

– IMPORTANT – PLEASE COMPLETE FOR THE RELEVANT ORGANISMS:
HAEMOPHILUS
INFLUENZAE
DOSE

23. If <15 years of age and serotype ‘b’ or ‘unk’ did
patient receive Haemophilus influenzae b vaccine?

DATE GIVEN
Mo.

Day

1

Yes

2

No

9

24. What was the serotype?

Unk

If YES, please complete the list below.

VACCINE NAME/MANUFACTURER

LOT NUMBER

_________________________________________________

___________________

Year

1
2
3
4

_________________________________________________

___________________

_________________________________________________

___________________

_________________________________________________

NEISSERIA MENINGITIDIS
3

C

5

W135

9

Unk

2

B

4

Y

6

Not groupable

8

Other (specify) ___________________________________________

Yes

2

No

9

9

3

a

4

c

5

d

6

e

Not Tested or Unk

7

f

8

Other
(specify) _______________________

1

Yes 2

No 9

DATE GIVEN
List most recent date for each vaccine

VACCINE NAME/MANUFACTURER

Unk

Not Typeable

26. Is patient currently attending college?
(15 – 24 years only)

25. What was the serogroup?

A

Mo.

1

b

___________________

1

27. Did patient receive meningococcal vaccine?

1
2

Day

_______________

Menactra, tetravalent meningococcal conjugate vaccine

_______________

Other (specify) ___________________________________

_______________

Not Known

Yes

2

No

9

DATE GIVEN
Mo.

28. If <15 years of age did patient receive
pneumococcal conjugate vaccine?
1

_______________

DOSE

STREPTOCOCCUS PNEUMONIAE

Day

2

If YES, please complete the following information:

3
4

GROUP A STREPTOCOCCUS

(#29–31 refer to the 7 days
prior to first positive culture)

29. Did the patient have surgery ? 1

Yes
Mo.

2
Day

No

9

Unk

VACCINE NAME/MANUFACTURER

LOT NUMBER

_____________________________________________________

_______________

_____________________________________________________

_______________

_____________________________________________________

_______________

_____________________________________________________

_______________

Year

1

Unk

LOT NUMBER

Year

Menomune, tetravalent meningococcal polysaccharide vaccine

If YES, please complete the following information:

Unk

30. Did the patient deliver a baby
(vaginal or C-section)?
1

Yes 2

No 9

Year

Mo.

31. Did patient have:

Unk
Day

Year

If YES,
date of delivery:

If YES,
date of surgery:

1

Varicella?

1

Penetrating trauma?

1

Blunt trauma?

1

Surgical wound?
(post operative)

1

Burns?

32. COMMENTS:

– SURVEILLANCE OFFICE USE ONLY –
33. Was case first
identified through
audit?
1

Yes

2

9

Unk

No

34. CRF Status:
1
2
3
4

Complete
Incomplete
Edited & Correct
Chart unavailable
after 3 requests

35. Does this case have
recurrent disease with
the same pathogen?
1

Yes

9

Unk

2

36. Date reported to EIP site

If YES, previous
(1st) state I.D.

Mo.

No

Submitted By:

Phone No.: (

)

Physician’s Name:

Phone No.: (

)

CDC 52.15A

REV. 12-2004

– ACTIVE BACTERIAL CORE SURVEILLANCE CASE REPORT –

Day

37. Initials
of S.O.

Year

Date:

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