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HomeMy WebLinkAboutacphd-infection-control-transfer-form-20251015pdfINFECTION CONTROL TRANSFER FORM This form should be sent with the patient/resident upon transfer. https://acphd.org/cro/ Demographics Patient/Resident (Last Name, First Name): Date of Birth: Transfer Date: Sending Facility Name: Transferring Facility Type: *Please select as applicable based on licensing designation  Acute Care Hospital Long Term Acute Care Hospital Ventilator Equipped SNF(Sub-acute)  Skilled Nursing Facility Residential Care for Elderly/Assisted Living/Memory Care  Other: Is sending facility in current/Suspected Outbreak? Yes No If yes, specify type of outbreak: Contact Name: Contact Phone: Receiving Facility Name: Has receiving facility been notified? Yes No Precautions and PPE Currently in Isolation Precautions?  Yes  No If Yes, check:  Contact  Droplet  Airborne  Enhanced Standard* PERSONAL PROTECTIVE EQUIPMENT CONSIDERATIONS CHECK ALL PPE TO BE CONSIDERED AT RECEIVING FACILITY  Masks  Gloves  Gowns  N95  PAPR  Eye Protection Organisms ORGANISMS (Include copy of lab results with organism ID and antimicrobial susceptibilities.)  Patient is NOT known to be colonized or infected with any multidrug-resistant or other organisms requiring precautions (skip)  Patient has MDRO or other lab results requiring precautions (record organism(s), specimen source, collection date)  Exposed to MDRO/other (record organism(s) and last date(s) of exposure if known) Organism Carbapenemase (if applicable)** Source Date  Candida auris (C. auris)  Clostridioides difficile (C. diff)  Acinetobacter baumannii, multidrug-resistant (e.g., CRAB**)  Carbapenem-resistant Enterobacterales (CRE**)  Pseudomonas aeruginosa, multidrug-resistant (e.g., CRPA**)  Extended-spectrum beta-lactamase (ESBL)-producer  Methicillin-resistant Staphylococcus aureus (MRSA)  Vancomycin-resistant Enterococcus (VRE)  Positive molecular screening test, organism unknown**  Other, specify: (e.g., SARS-CoV-2 (COVID-19), lice, scabies, disseminated shingles (Herpes zoster), norovirus, influenza, tuberculosis) **Note specific carbapenemase(s) (e.g., NDM, KPC, OXA-23) if known Symptoms/Risk Factors for Transmission Check yes to any that currently apply**:  Concerning rash (e.g., vesicular)  No Symptoms requiring additional PPE  Cough/uncontrolled respiratory secretions  Acute diarrhea or incontinent of stool  Incontinent of urine  Draining wounds  Vomiting  Other uncontained bodily fluid/drainage **NOTE: Appropriate PPE required i incontinent/drainage/rash NOT contained. Does the patien currentl have an o the ollowing devices?  Yes  No  Tracheostomy/Endotracheal tube  Central line/PICC, Date inserted:  Urinary catheter, Date inserted:  Suprapubic catheter  Colostomy  Percutaneous gastrostomy tube  Rectal tub  Hemodialysis catheter Affix patient label here Updated 10.15.2025