Dialysis Log Form

OMB No. 0920-0666

Exp. Date: 09-30-2012

Dialysis Log Form

FACILITY ID# :

Month/Year:__________/__________

For each hospitalization, IV antimicrobial start, or patient with a positive blood culture, complete one row on

this Log Form and complete one Dialysis Event Form.

Data from this form are not entered­­­this form is for your own use.

Incident

Date

Patient’s Name

Problem

Form

(mm/dd)

Completed?

1.

/

Y

2.

/

Y

3.

/

Y

4.

/

Y

5.

/

Y

6.

/

Y

7.

/

Y

8.

/

Y

9.

/

Y

10.

/

Y

11.

/

Y

12.

/

Y

13.

/

Y

14.

/

Y

15.

/

Y

16.

/

Y

17.

/

Y

18.

/

Y

19.

/

Y

20.

/

Y

Assurance of Confidentiality: The 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 242b, 242k, and 242m(d)).

Public reporting burden of this collection of information is estimated to average 1 hour 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 57.110