Form 0920-0978 CDI LTCF Call script survey

Form Approved
OMB No. 092-0978
Expires xx/xx/xxxx

Emerging Infections Program C. difficile Surveillance
Nursing Home Telephone Survey
Facility Name_________________________________ Phone number__________________________
Hi, I’m _____________ and I’m calling from the____ [EIP site]________ Emerging Infections Programs,
agents of the _______[health department]________. We are calling area nursing homes and long-term
acute care facilities in ______[name of the county]______to ask a few questions about patient
specimens submitted for laboratory testing. Who would be the best person for me to talk to?
Speaking to correct person:

YES (proceed)

NO (go to question 3)

Record name and title:________________________________
Phone number: _________________________________
Once you’re speaking to the correct person:
1. Is your facility a free-standing facility?
□ Yes
□ No, which hospital is your facility affiliated with? _______________
2. Do you collect stool specimens in the facility to be sent for Clostridioides difficile testing?
□ YES

□ NO

If YES, Do you send all your stool specimens for C. diff testing to a reference laboratory?
□ YES (what is the name of the reference lab: ______________________________)
□ No, please name the laboratories you send stool specimens for C. diff testing?
Name: ________________________________ Phone number: ___________________________
Name: ________________________________ Phone number: ___________________________
Name: ________________________________ Phone number: ___________________________
3. If NO, Name of person and title:_______________________
Phone number:_______________________________
Best time to reach this person:___________________
Public reporting burden of this collection of information is estimated to average 5 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/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia
30329; ATTN: PRA (0920-0978).