Infection Control Form

Infection Control Report Form Date: ____________ Resident Name: _______________________________ Type of Infection Bacteria

Urinary

Stool

Wound

Room #: _________ Nares

MRSA ESBL VRE C-DIFF E-COLI

Other: ________________

Other: ________________

Onset Date: _______________ Was resident residing in facility at the time of diagnosis?

Yes / No

Was Infection Hospital acquired?

Yes/ No

Were there any Signs and Symptoms of Infection prior to Lab Findings? _______________________________________________________________________ _______________________________________________________________________ What interventions prior to findings were taken to prevent further spread of infection? ________________________________________________________________________ ________________________________________________________________________ How did the resident acquire the infection? ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ What form of treatment is resident receiving? ________________________________________________________________________ ________________________________________________________________________ What was result of post treatment LAB findings? ________________________________________________________________________ ________________________________________________________________________ Resolution Date of Infection: _______________________________ Additional comments: _____________________________________________________ Signature of person completing form:________________________________________