Hospital Infection Surveillance Form
Use this form to record a hospital infection surveillance case, including location, timing, clinical details, suspected source, actions taken, and reporting staff information.
Case Identification
Incident Date and Time
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Hospital Unit / Ward / Location
*
Infection Type / Category
*
Please Select
Bloodstream Infection
Surgical Site Infection
Urinary Tract Infection
Pneumonia
Central Line-Associated Infection
Ventilator-Associated Event
Gastrointestinal Infection
Skin / Soft Tissue Infection
Other
Patient Category / Role
*
Please Select
Inpatient
Outpatient
ICU Patient
Neonatal Patient
Surgical Patient
Emergency Department Patient
Day Surgery Patient
Other
Clinical and Exposure Details
Date of symptom/sign onset
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Observed signs/symptoms
*
Suspected source or exposure
Organism/pathogen if known
Surveillance Follow-Up
Infection control actions taken
*
Isolation precautions
Contact tracing
Environmental cleaning
Specimen retesting
Antibiotic review
Patient transfer review
Other
Reporting staff name and role
*
First Name
Last Name
Report submission date and time
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Submit
Should be Empty: