Appendix H: Concerned- Uncomfortable- Safety (CUS) Communication Tool Minnesota Antimicrobial Stewardship Program Toolkit for Long-term Care Facilities www.health.state.mn.us I am Concerned about my resident's condition. I am Uncomfortable with my resident's condition. I believe the Safety of the resident is at risk. I am concerned that: [Describe your concern about the resident] I am uncomfortable with: [Explain why you’re concerned about the resident] I believe: [Describe why the safety of the resident is at risk] Minnesota Department of Health Infectious Disease Epidemiology, Prevention and Control Division 651-201-5414 www.health.state.mn.us 1-877-676-5414 12/2014 Adapted from Module 2: Communicating Change in a Resident's Condition: Improving Patient Safety in Long-Term Care Facilities. June 2012. Agency for Healthcare Research and Quality, Rockville, MD.