HomeMy WebLinkAboutinfection-control-transfer-form-remediated-adaINFECTION CONTROL TRANSFER FORM
This form should be sent with the patient/resident upon transfer.
Carbapenem-Resistant Organisms
Demographics
Patient/Resident (Last Name, First Name):
Date of Birth: Transfer Date:
Sending Facility Name:
Transferring Facility Type
Please select as applicable based
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
☐
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
☐Masks ☐ Gloves ☐Gowns ☐N95
☐PAPR ☐Eye Protection
Organisms
ORGANISMS lab results
☐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 (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 Herpes zoster
Symptoms/Risk Factors for Transmission
Check yes to any that currently apply***: ☐
☐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 if incontinent/drainage/rash NOT contained.
☐
No Symptoms
requiring additional
PPE
Does the patient currently have any of the following devices? ☐ Yes ☐ No
☐Tracheostomy/Endotracheal tube ☐Suprapubic catheter ☐ Colostomy
☐Central line/PICC, Date inserted:☐Percutaneous gastrostomy tube ☐ Rectal tube
☐Urinary catheter, Date inserted:☐Hemodialysis catheter
Updated 10.15.2025
Affix patient label here