Kansas Department of Health and Environment
Interfacility Infection Control Transfer Form
Personal Protective Equipment for Safe Patient Contact and Infection Prevention
Please check what is needed:
Standard
Precautions
Only
Standard Gown Gloves Surgical
(Droplet Mask)
Respirator
(N95/PAPR)
(Airborne Mask)
Please check:
Clostridioides dicile infection (CDI)
Carbapenem - Resistant Bacteria (CRE, CRPA, CRAB)
Other MDRO (VRSA, MRSA, ESBL, VRE): ______________________
Other communicable disease:________________________________________
No communicable disease or resistant organisms
Name: ______________________________________________________
Phone Number: _______________________________________________
Role (Check one):
Social Worker Case Manager Nurse Doctor Other: ____________
Point of Contact:
Place patient label here:
Patient Name:_______________________
DOB: ______________________________
Date of Admission:____________________
Date of Discharge:____________________
Developed in partnership with the Kansas Healthcare-Associated Infections and Antimicrobial
Resistance Advisory Group Multi-Drug Resistant Organism Task Force.
This form available at: www.kdheks.gov/epi/hai.htm under "Resources”.
For questions regarding isolation precautions, please call the 24/7 Epidemiology Hotline at 877-427-7317.
Infection Colonized
Infection Colonized
Infection Colonized
Laboratory/culture results pending
