NAUSP Contributor Survey Demographic survey for contributors Date survey completed: Click here to enter a date. Name of person completing this survey: State: Choose an item. Click here to enter text. Contact details Hospital name: Click here to enter text. Primary NAUSP contact name: Click here to enter text. Telephone contact: Click here to enter contact no. (incl area code) 4 Primary NAUSP contact email : Click here to enter email address Demographic information Bed numbers (see Explanatory Notes) (where allocated beds fluctuate, please give estimate) Click here to enter numeric figure Total bed number (average available): Inclusions A. Medical beds: Number B. Surgical/Ortho beds: Number Level II: D. HDU2: Number E. Emergency beds Number F. Obstetric beds: Number G. CCU: Number H. Burns: Number I. Spinal: Number J. Stroke: Number K. Vascular: Number L. Respiratory: Number M. Neurology: Number N. Renal (not dialysis): Number O. Haematology/Oncology: Number C. Intensive care beds1: (specify) Level III: P. Other Inclusion: Number Number Number Level I: Number Type description Total number of INCLUDED beds (Add A to P) = 3 Number Exclusions Q. Paediatric: Number R. Neonatal: Number S. Medical Day Units: Number T. Surgical Day Units: Number U. Residential Aged Care: Number V. Non-acute rehabilitation: Number W. Mental Health: Number X. Palliative Care: Number Y. Renal Dialysis Number Z. Other exclusion: Number Type description Total number of EXCLUDED beds (Add Q to Z) = Number Explanatory Notes 1. For ICU classifications refer to CICM document http://www.cicm.org.au/Resources/ProfessionalDocuments. NAUSP only reports ICU data for Principal Referral or Large Public Acute hospitals with Level II or Level III ICU beds. 2. High Dependency Unit (HDU) listed separately for sites with a separate unit. Can be left blank. 3. Total beds should equal Included beds plus Excluded beds. 4. AMS Pharmacist/primary report recipient (including data enquiries, report comments). Specialist services Solid organ transplants (check as relevant) ☐ Heart ☐ Kidney ☐ Liver ☐ Lung ☐ Other: Click here to specify September 2015 Version 4 Page 1 of 3 Surgical specialities (check as relevant) ☐ Cardiac ☐ Gynaecology ☐ Plastic Surgery ☐ Neurosurgery ☐ Vascular ☐ Orthopaedic ☐ Otolaryngology (ENT) ☐ Thoracic ☐ Oral/ maxillofacial/ craniofacial ☐ Trauma ☐ Urology ☐ Ophthalmology ☐ Gastrointestinal ☐ Other: (specify) Click here to enter text. Stem cell transplants (check as relevant) ☐ Autologous only ☐ Allogeneic Other specialist services of interest (check as relevant) ☐ Burns unit ☐ Cystic Fibrosis ☐ Haematology/Oncology ☐ HIV/Hepatitis ☐ Infectious Diseases ☐ Renal dialysis Antimicrobial stewardship resources AMS Governance group or committee: ☐ Yes ☐ No Date started (approx.): Enter month-year AMS Pharmacist: ☐ Yes ☐ No Date started (approx.): Enter month-year ID Physician for AMS: ☐ Yes ☐ No Date started (approx.): Enter month-year Antimicrobial restriction policy: ☐ Yes ☐ No Date started (approx.): Enter month-year Date started (approx.): Enter month-year Electronic antimicrobial approval system: ☐ Yes ☐ No For office use only Date received: NAUSP Start Date: NAUSP Codes: AIHW Classification: AIHW Bed Numbers: AUSS Locations: -ICU AUSS Regions: Coast LHD For more information National Antimicrobial Utilisation Surveillance Program Communicable Disease Control Branch Telephone: 1300 232 272 Email: antibio@health.sa.gov.au www.health.sa.gov.au/antimicrobials Public – I1 – A1 © Department for Health and Ageing, Government of South Australia. All rights reserved. May 2015 Version 4 Page 2 of 3