ICU Infection Surveillance Form
Track ICU-acquired or suspected infections with key clinical and laboratory details.
Patient or Encounter Identifier (Do not use sensitive IDs)
*
ICU Unit
*
Please Select
Medical ICU
Surgical ICU
Cardiac ICU
Neuro ICU
Other
Date and Time of Surveillance
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Suspected Infection Type
*
Please Select
Pneumonia (VAP)
Bloodstream Infection (BSI)
Urinary Tract Infection (UTI)
Surgical Site Infection (SSI)
Other
Suspected Source or Site of Infection
*
Please Select
Lung/Respiratory tract
Bloodstream
Urinary tract
Surgical site
Gastrointestinal tract
Other
Date of Infection Onset
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Key Signs and Symptoms
*
Fever
Leukocytosis/Leukopenia
Purulent drainage
Cough/Respiratory distress
Hypotension
Other
Cultures or Laboratory Results
*
Treatment/Antibiotics Initiated
*
Follow-up Actions or Notes
Submit Surveillance
Should be Empty: