Kesling Doh 4018

Health Care Facility
Infection Control (Nosocomial) Report
New York State Department of Health

Facility Name:
____________________________________________________ PFI (4-digit facility # required): ________________
Street Address:
____________________________________________________ Census: ___________________________________
Street Address:
____________________________________________________
City:
____________________________________________________ County: ____________________________________
Zip Code:
____________________________________________________ Region: ____________________________________
Type:
Hospital
Contact Person:
____________________________________________________ Phone Number: _____________________________
Title:
____________________________________________________ Fax Number: _______________________________
E-mail:
____________________________________________________
Date of Report:
____________________________________________________
Type of Report:
Outbreak/Increased incidence
Single case nosocomially-acquired reportable communicable disease (submission of DOH-389 is required)
Other: _______________________
Site(s) of infection:
(check all that apply)
LTCF
Blood
Respiratory
Eye Gastrointestinal Other: ____________________________

Skin Urinary
DATE OF ONSET OF SYMPTOMS: (earliest case) ____________________

PREDOMINATE SYMPTOMS AND DURATION OF ILLNESS: (if fever, include range) ___________________________________________
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
NUMBER OF LABORATORY CONFIRMED CASES TO DATE:
Patients: __________
Staff: __________
NUMBER OF SUSPECT CASES TO DATE:
Staff: __________
NUMBER TRANSFERRED TO HOSPITAL:
Staff: __________
NUMBER OF CASES RESULTING IN DEATH:
Staff: __________
AFFECTED LOCATION(S) IN FACILITY:

Number of Units: __________
Number of Floors: __________
Cardiac
General Medicine
Med/Surg
Surgical
Nursery
OB/GYN
Oncology
Not Applicable
Ortho
Pediatrics
Rehab
Other: ___________________________
AFFECTED LOCATION TYPES:
AFFECTED ICU TYPES:
Cardiac
General
Medical
Surgical
Neonatal
Neurological
Pediatrics
Not Applicable
Other:
___________________________
AFFECTED TRANSPLANT UNIT TYPES:
Bone Marrow
Cardiac
Not Applicable
Renal Cardiac
Liver
Other
OTHER UNIT TYPE: ____________________________________

DOH 4018
BHAI 4/2009
Page 1 of 2
Please FAX to 518-402-5165
CAUSATIVE AGENT: ________________________________________________
Suspect
SUSPECT/CONFIRMED:
Confirmed
HAVE ANY LABORATORY SPECIMENS BEEN COLLECTED:
Yes
No
If yes, what specimens were collected? (check all that apply):
Blood
CSF
Nasal Pharyngeal
Urine
Sputum
Stool
Tracheal Aspirate
Other: ___________________
If yes, what types of tests were performed? (check all that apply):
Culture
PCR
Rapid Antigen
Serology
Urine Antigen
Other: ________________
Name of Laboratory: _____________________________________________________________________

CONTROL MEASURES TAKEN BY FACILITY (check all that apply):
Antibiotics
Antiviral
Cohort Patients
Cohort Staffing
Education/Inservice
Isolation
Limit/modify patient activities
Minimize floating
Notify Visitors
Reinforce Handwashing
Other: ____________________________
Additional measures not checked above: __________________________________________________________________________________

_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
FOR OFFICE USE ONLY
No close out form for this case (e.g. Scabies):
Paper Log Number:
__________________________
Level of Investigation: __________________________
Date Received:
__________________________
Lead Investigator:
__________________________
Received by:
__________________________
Follow-up by:
__________________________
Central Office Contact to Facility:
Yes
No
If yes, date: __________________________________
Regional Epidemiology Staff Contact to Facility
Yes
No
Date of Initial Contact: _________________________
Comments: __________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
Stat:
DOH 4018
BHAI 4/2009
Page 2 of 2
Please FAX to 518-402-5165

Kesling Doh 4018

Uploaded by

Document Information

Original Description:

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Kesling Doh 4018

Uploaded by

Copyright:

Available Formats

Health Care Facility

Infection Control (Nosocomial) Report

New York State Department of Health

____________________________________________________ PFI (4-digit facility # required): ________________

____________________________________________________ Census: ___________________________________

____________________________________________________ County: ____________________________________

____________________________________________________ Region: ____________________________________

____________________________________________________ Phone Number: _____________________________

____________________________________________________ Fax Number: _______________________________

Eye Gastrointestinal Other: ____________________________

DATE OF ONSET OF SYMPTOMS: (earliest case) ____________________

NUMBER OF SUSPECT CASES TO DATE:

NUMBER TRANSFERRED TO HOSPITAL:

NUMBER OF CASES RESULTING IN DEATH:

AFFECTED LOCATION(S) IN FACILITY:

Number of Floors: __________

AFFECTED LOCATION TYPES:

AFFECTED ICU TYPES:

AFFECTED TRANSPLANT UNIT TYPES:

OTHER UNIT TYPE: ____________________________________

CAUSATIVE AGENT: ________________________________________________

HAVE ANY LABORATORY SPECIMENS BEEN COLLECTED:

If yes, what specimens were collected? (check all that apply):

Name of Laboratory: _____________________________________________________________________

Limit/modify patient activities

Additional measures not checked above: __________________________________________________________________________________

Level of Investigation: __________________________

Central Office Contact to Facility:

If yes, date: __________________________________

Regional Epidemiology Staff Contact to Facility

Date of Initial Contact: _________________________

You might also like

____________________________________ PFI (4-digit facility # required):

__________________ Census: _

________________ County:

________________ Region:

________________________ Phone Number: _

______________________ Fax Number: _