OMB No 0920 0666 Exp Date xxxxxxxx Dialysis

OMB No. 0920 -0666 Exp. Date: xx-xx-xxxx Dialysis Event Page 1 of 4 *required for saving Facility ID: *Patient ID: Event #: Social Security #: Secondary ID: Patient Name, Last: *Gender: F M First: Other Middle: *Date of Birth: Ethnicity (Specify): *Event Type: DE Race (Specify): *Date of Event: *Location: Risk Factors *Vascular accesses: (check all that apply) Fistula Graft Tunneled central line Nontunneled central line Hybrid access Access Placement Date: Date Unknown: ___/____/______ ___/______ Event Details *Specify Event: (check one or more) IV antimicrobial start. Was IV vancomycin started? Yes No Patient with a positive blood culture: * Suspected source of positive blood culture (check one): Vascular access A source other than the vascular access Contamination Uncertain If positive blood culture, specify pathogen on pages 2 -3. Pus, redness, or increased swelling at vascular access site Check the access site(s) with pus, redness, or increased swelling: fistula graft tunneled central line nontunneled central line hybrid access *Problem(s): (check one or more) Fever >37. 8°C (100°F) oral Chills or rigors Drop in blood pressure Wound (NOT related to vascular access) with pus or increased redness Cellulitis (skin redness, heat, or pain without open wound) Pneumonia or respiratory infection Other (specify) __________________________ *Outcome: Hospitalization Death Yes No Unknown 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 242 b, 242 k, and 242 m(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. 109 (Front) Rev 2, v 6. 4

Page 2 of 4 Pathogen # OMB No. 0920 -0666 Exp. Date: xx-xx-xxxx Dialysis Event Gram-positive Organisms Staphylococcus _____ coagulase-negative VANC SIRN (specify): _____________ Enterococcus _____ spp. (specify) _____ Enterococcus _____ faecium AMP SIRN CIPRO/LEVO/MOXI SIRN STREPHL§ SRN AMP SIRN TETRA SIRN CIPRO/LEVO/MOXI SIRN STREPHL§ SRN Staphylococcus _____ aureus Pathogen # TETRA SIRN DAPTO S NS N DOXY/MINO SIRN TIG S NS N VANC SIRN CHLOR SIRN CIPRO/LEVO/MOXI SIRN CLIND SIRN DAPTO S NS N LNZ SRN OX/CEFOX/METH SIRN QUIDAL SIRN RIF SIRN GENTHL§ SRN LNZ SIRN DOXY/MINO ERYTH SIRN TETRA SIRN QUIDAL SIRN GENT SIRN TIG TMZ VANC S NS N SIRN Gram-negative Organisms Acinetobacter _____ spp. (specify) ______ AMK SIRN AMPSUL IMI Escherichia AMK SIRN Enterobacter _____ spp. (specify) ______ CEFUR SIRN CDC 57. 109 (Back) Rev 2, v 6. 4 CEFTAZ CIPRO/LEVO COL/PB GENT SIRN PIP/PIPTAZ TETRA/DOXY/MINO TMZ TOBRA SIRN AMPSUL/AMXCLV AZT CEFAZ CEFEP CEFOT/CEFTRX SIRN SIRN CEFOX/CETET CHLOR SIRN CIPRO/LEVO/MOXI COL/PB ERTA SIRN IMI MERO/DORI PIPTAZ TETRA/DOXY/MINO TIG TMZ TOBRA SIRN SIRN AMK AMP SIRN CEFTAZ CEFUR SIRN AMPSUL/AMXCLV AZT CEFAZ CEFEP CEFOT/CEFTRX SIRN SIRN CEFOX/CETET CHLOR SIRN CIPRO/LEVO/MOXI COL/PB ERTA SIRN GENT IMI MERO/DORI PIPTAZ TETRA/DOXY/MINO TIG TMZ TOBRA SIRN SIRN Klebsiella spp. AMK SIRN _____ (specify) ______ AMP SIRN CEFTAZ GENT CEFEP SIRN MERO/DORI SIRN _____ coli AZT SIRN AMP SIRN CEFTAZ CEFUR SIRN AMPSUL/AMXCLV AZT CEFAZ CEFEP CEFOT/CEFTRX SIRN SIRN CEFOX/CETET CHLOR SIRN CIPRO/LEVO/MOXI COL/PB ERTA SIRN GENT IMI MERO/DORI PIPTAZ TETRA/DOXY/MINO TIG TMZ TOBRA SIRN SIRN

Page 3 of 4 Pathogen # Gram-negative Organisms Serratia _____ marcescens Pseudomonas _____ aeruginosa _____ Pathogen # Stenotrophomonas maltophilia OMB No. 0920 -0666 Exp. Date: xx-xx-xxxx Dialysis Event AMK SIRN (continued) AMP SIRN AMPSUL/AMXCLV AZT CEFAZ CEFEP CEFOT/CEFTRX SIRN SIRN CEFTAZ CEFUR CEFOX/CETET SIRN GENT IMI SIRN MERO/DORI CIPRO/LEVO/MOXI COL/PB ERTA SIRN PIPTAZ TETRA/DOXY/MINO TIG TMZ SIRN SIRN AMK AZT SIRN IMI MERO/DORI PIP/PIPTAZ TOBRA SIRN TETRA/MINO SIRN TICLAV TMZ SIRN LEVO SIRN CEFEP SIRN CHLOR SIRN CEFTAZ CIPRO/LEVO COL/PB GENT SIRN TOBRA Fungal Organisms _____ Candida spp. ANID S NS N (specify) CASPO S NS N FLUCO S S-DD R N FLUCY SIRN ITRA S S-DD R N MICA S NS N VORI S S-DD R N _________ Pathogen # _____ Other Organisms Organism 1 ____ ____ ____ (specify) Drug 1 Drug 2 Drug 3 Drug 4 Drug 5 Drug 6 Drug 7 Drug 8 Drug 9 _________ SIRN SIRN SIRN Organism 2 ____ ____ ____ (specify) Drug 1 Drug 2 Drug 3 Drug 4 Drug 5 Drug 6 Drug 7 Drug 8 Drug 9 _________ SIRN SIRN SIRN Organism 3 ____ ____ ____ (specify) Drug 1 Drug 2 Drug 3 Drug 4 Drug 5 Drug 6 Drug 7 Drug 8 Drug 9 _________ SIRN SIRN SIRN Result Codes S = Susceptible I = Intermediate R = Resistant NS = Non-susceptible S-DD = Susceptible-dose dependent § GENTHL and STREPHL results: S=Susceptible/Synergistic and R=Resistant/Not Synergistic N = Not tested Drug Codes: AMK = amikacin AMP = ampicillin AMPSUL = ampicillin/sulbactam AMXCLV = amoxicillin/clavulanic acid ANID = anidulafungin AZT = aztreonam CASPO = caspofungin CEFAZ= cefazolin CEFEP = cefepime CEFOT = cefotaxime CEFOX= cefoxitin CEFTAZ = ceftazidime CDC 57. 109 (Back) Rev 2, v 6. 4 CEFTRX = ceftriaxone CEFUR= cefuroxime CETET= cefotetan CHLOR= chloramphenicol CIPRO = ciprofloxacin CLIND = clindamycin COL = colistin DAPTO = daptomycin DORI = doripenem DOXY = doxycycline ERTA = ertapenem ERYTH = erythromycin FLUCO = fluconazole FLUCY = flucytosine GENT = gentamicin GENTHL = gentamicin – high level test IMI = imipenem ITRA = itraconazole LEVO = levofloxacin LNZ = linezolid MERO = meropenem METH = methicillin MICA = micafungin MINO = minocycline MOXI = moxifloxacin OX = oxacillin PB = polymyxin B PIP = piperacillin PIPTAZ = piperacillin/tazobactam QUIDAL = quinupristin/dalfopristin RIF = rifampin STREPHL = streptomycin – high level test TETRA = tetracycline TICLAV = ticarcillin/clavulanic acid TIG = tigecycline TMZ = trimethoprim/sulfamethoxazole TOBRA = tobramycin VANC = vancomycin VORI = voriconazole

Dialysis Event OMB No. 0920 -0666 Exp. Date: xx-xx-xxxx Page 4 of 4 Custom Fields Label ________________________ ________________________ Comments CDC 57. 109 (Back) Rev 2, v 6. 4 ___/___ ___________ ___________ Label ________________________ ________________________ ___/___ ___________ ___________