Get Cdph Interfacility Infection Control Transfer Form

The CDPH Interfacility Infection Control Transfer Form is essential for ensuring a seamless and safe transition of patients between facilities. This guide provides comprehensive steps to assist you in accurately completing the form online.

Follow the steps to fill out the CDPH Interfacility Infection Control Transfer Form online.

1. Click the ‘Get Form’ button to obtain the document and open it for editing.
2. Provide the sending facility's name at the top of the form to identify where the patient is transferring from.
3. Enter the patient's last name and first name. This information is vital for maintaining accurate records.
4. Fill in your name as the person completing the form to ensure contactability regarding the transfer.
5. Record the name and address of the receiving facility where the patient will be sent.
6. Input your contact telephone number and fax number for communication purposes.
7. Provide the patient's date of birth and medical record number for identification.
8. List an alternate contact name and their telephone or fax number in case additional information is needed.
9. Indicate whether the patient currently has or is known to have a positive culture of a multidrug-resistant organism (MDRO) by checking the appropriate boxes and attaching any relevant culture reports.
10. Answer whether the patient is showing symptoms such as fever or open draining wounds. Mark the relevant checkboxes.
11. Specify if the patient is currently in isolation and the type of isolation, if applicable.
12. For patients with medical devices, record the type and the approximate date of insertion where required.
13. If the patient is on antibiotics, mark 'yes' and provide the antibiotic name and dosage.
14. Fill out the vaccination history section, indicating which vaccines have been administered, dates, lot and brand numbers, and whether the patient self-reports receiving them.
15. Once all sections are completed, save your changes, download, print, or share the form as needed for the patient's transfer.

Complete the CDPH Interfacility Infection Control Transfer Form online today to ensure safe patient transfers.