1. * * * * * * * * * Form H: Hospital-based data by surveillance period
Hospital code:
Hospital type:
Primary
Secondary
Tertiary *
Specialised hospital (please specify): *
Surveillance period: From (dd/mm/yyyy): *
Surveillance period: To (dd/mm/yyyy):
Specify for surveillance period: *
Number of beds: *
Number of discharges/admissions: *
Number of patient days *
Number of HA*-CDI cases:
Number of CA*-CDI cases or CDI cases of unknown origin: *
Number of patients tested for CDI:
Number of positive tested patients:
*: HA: healthcare-associated; CD: community-associated
Exclusion of wards:
Yes No
If wards were excluded: Which wards?
Form Version 0.2
Important note: all wards should be included for the surveillance of CDI (also for the pilot study), exclusion of wards is not allowed. If despite this recommendation certain wards were excluded, it is crucial that the aggregated denominator data are provided for the included wards only!