MULTI-DRUG RESISTANT ORGANISM (MDRO) REPORTING FORM
Carbapenem-Resistant Organism (CRE, CRPA, CRA), Candida auris, pan-resistant organisms, and
Vancomycin-Intermediate/Resistant Staphylococcus aureus (VISA, VRSA)
Fax completed forms to 877-427-7318 | Urgent matters or questions call 877-427-7317
This form and submission criteria available at: www.kdheks.gov/epi/disease_reporting.html
Today’s date:
PATIENT INFORMATION
Name:
Last First Middle
Mobile phone: Home phone:
Residential address:
City: State: Zip:
Date of Birth:
Race: Ethnicity: Sex:
D
ISEASE OR CONDITION INFORMATION
MDRO organism (genus, species):
Hospitalized?
Died? Laboratory/culture results attached:
Laboratory name: Specimen collection date:
Carbapenemase test (e.g., CarbaNP, PCR) result (attach):
Susceptibility from AST machine (e.g. Vitek) attached and numerical values listed?
Isolate submitted to state?
F
ACILITY AND PHYSICIAN INFORMATION
Facility name: Facility city:
Physician name: Phone #:
Name of person reporting: Phone #:
S
UPPLEMENTAL MDRO INFORMATION (INPATIENT SETTINGS: NOTIFICATION TO INFECTION CONTROL DEPT. RECOMMENDED)
Specimen collected in an inpatient setting (e.g., hospital, nursing home)?
Inpatient setting: was the patient placed on Contact Precautions?
Inpatient setting: was the patient’s medical record “flagged” as MDRO for future visits?
Where was the patient discharged to? Date:
Receiving facility notified of pending lab test(s) and MDRO status of patient?
Black
Asian
American Indian / Alaska Native
Native Hawaiian / Pacific Islander
Hispanic
Non-Hispanic
No
Yes → Hospital Name: Admitted: Discharged: __________________
No
Unknown
Test name: Positive Negative Not tested
Yes (date: ) No Unknown
Yes (inpatient) No (outpatient) Unknown
Yes No N/A (outpatient) Unknown
Yes No N/A (outpatient) Unknown
CRE, CRPA, CRA Candida auris Pan-resistant organism VISA, VRSA
