Infection Control Report

Infection Control Report — Form Fields

This healthcare template includes 6 fields. Document and report a suspected or confirmed healthcare-associated infection (HAI) or infection control breach. Supports infection prevention teams in tracking and containing outbreaks. Ensures compliance with reporting requirements. Free to customize and use on ZenBuild.

• Reporting Staff Member (text, required)
• Unit / Ward / Department (text, required)
• Type of Infection or Breach (dropdown selection, required) — options: Catheter-associated UTI (CAUTI), Central line bloodstream infection (CLABSI), Surgical site infection (SSI), Respiratory infection / VAP, C. difficile infection, PPE or hand hygiene breach, Other
• Status of incident (multiple choice, required) — options: Suspected – not yet confirmed, Confirmed case, Protocol breach (no patient exposure)
• Incident Description (long text, required)
• Actions Taken (long text, optional)