Form CDC 52.15A CDC 52.15A 2015 Active Bacterial Core Surveillance (ABCs) Case Repo

– ACTIVE BACTERIAL CORE SURVEILLANCE CASE REPORT –

Patient’s Name:

Phone No.: (
Patient
Chart No.:

(Last, First, MI.)

Address:

(Number, Street, Apt. No.)
(City, State)

)

Hospital:

(Zip Code)

2015 Active Bacterial Core
Surveillance (ABCs) CASE REPORT
Non-Bacteremic Pneumococcal Disease

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

A CORE COMPONENT OF THE EMERGING INFECTIONS PROGRAM NETWORK

OMB No. 0920-0978

– SHADED AREAS FOR OFFICE USE ONLY –
1. STATE:
(Residence of Patient)

2. STATE I.D.:

3. DATE FIRST POSITIVE URINE ANTIGEN TEST COLLECTED
(Date Specimen Collected)
Mo.

Year

4. CRF Status:
1

Complete

3

Edited & Correct

2

Incomplete

4

Chart unavailable
after 3 requests

6b. HOSPITAL I.D. WHERE
PATIENT TREATED:

6a. HOSPITAL/LAB I.D. WHERE
CULTURE IDENTIFIED:

5. COUNTY:
(Residence of Patient)
8a. AGE:

7. DATE OF BIRTH:
Mo.

Day

Day

9. SEX:

Year

8b. Is age in day/mo/yr?
1

Days 2

Mos. 3

10a. ETHNIC ORIGIN:

1

Male

1

Hispanic or Latino

2

Female

2

Not Hispanic or Latino

9

Unknown

Yrs.

10b. RACE: (Check all that apply)
1

White

1

Asian

1

Black

1

1

American Indian
or Alaska Native 1

Native Hawaiian
or Other Pacific Islander
Unknown

11. STERILE SITES FROM WHICH ORGANISM ISOLATED IN ADDITION TO UAT POSITIVE: (Check all that apply)
1

Blood

1

Peritoneal fluid

1

Bone

1

Joint

1

Other normally sterile site (specify) ______________________________________

1

CSF

1

Pericardial fluid

1

Muscle/Fascia/Tendon

1

Pleural fluid

1

Internal body site (specify) ______________________________________

Mo.

12. WAS PATIENT
HOSPITALIZED?

1

13. OUTCOME: 1

Yes

2

Survived 2

Day

Mo.

Year

If YES, date of admission:

No

Died 9

Day

Year

Date of discharge:

Unknown

14. UNDERLYING CAUSES OR PRIOR ILLNESSES: (Check all that apply OR if NONE or CHART UNAVAILABLE,check appropriate box) 1
1
1

AIDS or CD4 count <200
Alcohol Abuse, Current

1

Complement Deficiency

1

IVDU, Current

1

CSF Leak

1

IVDU, Past

1
1
1

Alcohol Abuse, Past
Asthma
Atherosclerotic Cardiovascular Disease
(ASCVD)/CAD

1

Current Smoker

1

Deaf/Profound Hearing Loss

1

Dementia

1
1
1
1
1
1
1

Bone Marrow Transplant (BMT)
Cerebral Vascular Accident (CVA)/Stroke
Chronic Kidney Disease
Current Chronic Dialysis
Chronic Skin Breakdown
Cirrhosis/Liver Failure
Cochlear Implant

1

Diabetes Mellitus

1
1
1
1
1
1

Emphysema/COPD
Heart Failure/CHF
HIV Infection
Hodgkin’s Disease/Lymphoma
Immunoglobulin Deficiency
Immunosuppressive Therapy (Steroids,
Chemotherapy, Radiation)

1
1
1
1
1
1

Leukemia
Multiple Myeloma
Multiple Sclerosis
Nephrotic Syndrome
Neuromuscular Disorder
Obesity

1
1

Parkinson’s Disease
Other Drug Use, Current

1

Other Drug Use, Past

1

Peripheral Neuropathy

None 1

Unknown

1
1

Plegias/Paralysis
Premature Birth (specify gestational
age at birth )
(wks)

1
1
1
1
1
1

Seizure/Seizure Disorder
Sickle Cell Anemia
Solid Organ Malignancy
Solid Organ Transplant
Splenectomy/Asplenia
Systemic Lupus Erythematosus (SLE)

1

Other prior illness (specify)

15. DID THE PATIENT HAVE A CHEST CT OR CHEST X-RAY WITHIN 72 HOURS OF ADMISSION?:
1

CT 2

X-ray 3

Both 4

Neither 9

Unknown

If yes, check all that apply from the radiology report:
Pneumonia/bronchopneumonia
1
Air space/alveolar density/opacity/disease
1
Consolidation
1
Atelectasis
1
Lobar (NOT interstitial) infiltrate
1
Cavitation
For pneumonia/consolidation/infiltrate
1
Pleural effusion
1
Single lobar
1
Pneumonitis
1
Multiple lobar infiltrate (unilateral) 1 Pulmonary edema
1
Multiple lobar infiltrate (bilateral)
1 Interstitial infiltrate
1

16. WAS THE PATIENT DIAGNOSED WITH PNEUMONIA?:

1

Yes

2

No*

9

1
1
1
1
1
1

Empyema
ARDS (acute respiratory distress syndrome)
Cannot rule out pneumonia
No evidence of pneumonia
Report not available
Other (specify
)
_____________________________________

Unknown*

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 information, including suggestions for reducing this burden to CDC,

Do not send the completed form to this address.

CDC 52.15A REV. 10-2014

– ACTIVE BACTERIAL CORE SURVEILLANCE CASE REPORT –

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