Skip Ribbon Commands
Skip to main content
NOTE: Prior to entering data, please update this page by pressing CTRL and F5 at the same time.  

Carbapenemase-producing Enterobacteriaceae (CPE) Online Surveillance Form

Please complete the Carbapenamase-producing Enterobacteriaceae (CPE) online surveillance form below following a positive isolate in a patient. Prior to entering information, please read the CPE online surveillance form user guide. Please note that once you exit or close the page, the data you entered will no longer be accessible.

Fields marked with asterisk (*) are required and those in grey font are automatically populated.

Submitter Details
a. Submitter's Name:*
b. Submission Date:
c. Hospital Corporation:*
d. LHIN:
e. Facility Number:
f. Name of Hospital:*
g. Institution Number:
h. Submitter's Telephone Number:*
i. Submitter's Email:*
Patient Details
j. Health Card No. (OHIP):
k. Date of Birth: (dd-mmm-yyyy e.g., 1-Dec-2001)
l. Sex:*
 Male     Female     Unknown
Specimen Information
1. Specimen ID#:*
2. Specimen Type (Check all that apply):*
 Blood
 Rectal swab/perirectal swab/stool
 Sputum
 Surgical site/wound, skin/soft tissue/burn
 Urine
 Other, specify 
3. Primary reason for specimen collection:*
3a. Date of specimen collection:* (dd-mmm-yyyy e.g., 1-Dec-2001)
4a. Has this patient been previously identified as colonized or infected?* Yes     No     Unknown
If yes, please complete the following for the previous positive isolate:*
4b. Specify hospital/laboratory:*
4c. Previous specimen collection date:* (dd-mmm-yyyy e.g., 1-Dec-2001)
4d. Please indicate the organism identified in the previous positive specimen:*
4e. Please indicate the type of resistance identified in the previous positive isolate:*
 IMP (Imipenemase Metallo-beta-lactamase)
 KPC (Klebsiella pneumoniae carbapenemase)
 NDM (New Delhi Metallo-beta-lactamase)
 OXA-48 (OXA-48 producing carbapenemase)
 VIM (Verona Integron-Encoded Metallo-beta-lactamase)
 Unknown
Patient Information
5. Reason for admission:*
6. Date of hospital admission/clinic visit:* (dd-mmm-yyyy e.g., 1-Dec-2001)
7a. During this admission to date, is the patient infected or colonized?*  Colonized only
 Infected (with or without colonization at other sites)
 Unknown
8. Based on the admission history, which chronic conditions does the patient have (check all that apply)?*
 Cancer (active, last 2 years)
 Chronic liver disease/cirrhosis
 Chronic lung disease ( e.g., COPD, asthma, chronic bronchitis, emphysema)
 Diabetes mellitus
 Heart disease (include e.g., MI, coronary artery disease, STEMI, CHF)
 Immunosuppression (include e.g., transplant, chemotherapy for cancer, prednisone or remicaide treatment)
 Renal failure
 Other, specify 
 Not applicable
9. Which type of ward/unit was the patient on when the specimen was collected?*  Emergency department
 Hospital's extended-stay units (e.g., CCC)
 Out-patient clinic and/or nursing/retirement home
 In-hospital
10. Was the patient hospitalized anywhere in the 12 months before this clinic visit or hospitalization?*  Yes     No     Unknown
11. Has the patient travelled outside of Canada in the last 12 months?*  Yes     No     Unknown
12. Based on the admission history, did this patient undergo endoscopic retrograde cholangiopancreatography (ERCP) within three months of CPE specimen collection?*  Yes     No     Unknown
13. Other comments:
Submit   Print      Exit
​​​​​​
Uncontrolled print copy. Valid only on day of Print: [date]
Page updated on [date/time] 05/01/2017 4:33 PM
© , Ontario Agency for Health Protection and Promotion