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
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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
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