An inter-facility infection prevention transfer form has been developed as part of a regional effort to improve communication between acute and long-term healthcare facilities. The purpose of the form is to convey information about a patient’s isolation precautions and the reason for their implementation to the receiving facility. The sending facility should record current infection and colonization information. The form is not intended to be a comprehensive documentation of microbiologic history and does not replace review of medical records and communication between care providers.
Please fill out this form and send it with all patients being transferred between facilities, regardless of whether or not they require isolation.
Please click here for the form.
Questions or feedback about the form may be addressed to Stephanie Black, MD, MSc at firstname.lastname@example.org or 312-746-6034.
:: Chicago Department of Public Health (CDPH)
:: Centers for Disease Control (CDC)
:: Morbidity & Mortality Weekly Report (MMWR)
:: World Health Organization (WHO)
:: Illinois State Medical Society (ISMS)
:: Illinois Department of Public Health (IDPH)
:: Illinois Department of Pubilc Health HAN
:: Infectious Diseases Society of America (IDSA)
:: Chicago Medical Society (CMS)
:: Food and Drug Administration (FDA)
:: American Public Health Association (APHA)