Inter-Facility Infection Prevention Transfer Form

This form may be completed so that important information regarding isolation precautions of patients may be shared between different healthcare facilities.  If known, infection and colonization history should be recorded. 

Facility Transfer Form


Please help us to improve this tool so that communication between institutions is optimized.  The following questions will help us make needed adjustments. Thank you!

  1. Approximately how much time did it take to fill out this form?
  2. Did you find this form useful as a recipient?  Or as a completer of the form for another institution?
  3. If you could change the form, how would you change it?
  4. Do you have any other ideas that would help facilitate communication about multi-drug resistant bacteria and viruses between healthcare facilities?

Foward any feedback on this form to