| Document Date: 2014-02-04 12:45:43
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City Facility / Secondary / Atlanta / Event / Patient / / Company AMP / / Facility Facility ID / / IndustryTerm access device / / MedicalCondition increased redness Urinary tract infection Cellulitis / Pseudomonas / Pneumonia / vascular access Contamination Uncertain Pus / pus / Fever / oral Chills / MS / ____Klebsiella pneumonia / / MedicalTreatment catheter / Dialysis / / Organization FDA / Medicare / / Person MICA S NS / / Position Reports Clearance Officer / / Product ceftazidime / levofloxacin / piperacillin / itraconazole / cefazolin / trimethoprim / linezolid / amoxicillin / gentamicin / doxycycline / ampicillin / cefotaxime / cefoxitin / CIPRO / erythromycin / ciprofloxacin / rifampin / sulfamethoxazole / fluconazole / cefuroxime / cefotetan / ceftriaxone / tobramycin / / ProvinceOrState Georgia / / Technology Dialysis / / URL http /
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Complete this form as indicated by the Dialysis Event Protocol Instructions for this form are available at http://www.cdc.gov/nhsn/forms/instr/57_502.pdf Page 1 of 4 *required for saving Facility ID: