Stop Hospital Infections: Share your story

Share Your Hospital Infection Story

Have you or a loved one contracted a hospital infection when you went in for surgery or other illness? We would like to hear your story, or any other comment you may have about your hospital experience.

(Your personal information will remain completely confidential unless you give us permission to use or share it below.)

Hundreds of people have contacted Consumers Union to share their hospital infection experiences. Read their stories.

Please answer the following questions to the best of your ability, with respect to either your own experience or the experience of your loved one who contracted a hospital-acquired infection. Questions marked with an "*" must be answered, while other questions are optional. Thanks for taking the time to do this. Your personal experience can really help us stop hospital infections in the future!

Question - Not Required - In what year did you contract a hospital infections?

*2.

Question - Required - In what kind of hospital facility did you or a family member get an infection. Acute care general hospital
Rehabilitation hospital
Childrens hospital
Other specialty hospital
Nursing home
Other source
Don't know

Question - Not Required - Describe your experience in your own words (the space below allows you to include as much detail as you like):

Question - Not Required - Name of hospital or facility:

(Maximum response 255 chars, approx. 5 rows of text)

*5.

Question - Required - When did you find out that you or your loved one had acquired an infection in the hospital? During the hospital stay
After leaving the hospital

*6.

Question - Required - In which area of the hospital did you or your loved one get a hospital infection? Intensive Care Unit
Pediatric Intensive Care Unit
General medical/surgical unit
Nursery or birthing center
Burn unit
Emergency or trauma unit
Other hospital unit
Don't know

Question - Not Required - To the best of your knowledge, was your hospital- acquired infection resistant to certain kinds of antibiotic treatment?

	Yes MRSA (Methicillin-resistant Staphylococcus aureus)
	Yes VRE (Vancomycin-resistant enterococci)
	Yes c.difficile (clostridium difficile)
	Yes other resistance type
	No
	Don't know

Question - Not Required - Your hospital-acquired infection resulted in (you may check multiple answers):

	no additional hospitalization or care
	antibiotic treatment in hospital or after discharge
	additional surgery
	extended length of hospital stay
	readmission to the hospital
	rehabilitation or other outpatient treatment
	permanent disability
	death

Question - Not Required - To the best of your knowledge, did your hospital- acquired infection increase the cost of your hospital stay?

*10.

Question - Required - It took about how long for you or your loved one to fully recover from your hospital-acquired infection? Less than a week
More than a week but less than a month
More than a month but less than six months
Six months to a year
More than a year
Still not fully recovered
Not applicable because person died

*11.

Question - Required - On a scale of 1 to 10, where 1 is relatively healthy and 10 is extremely sick, how would you rank your condition upon entrance to the hospital where you contracted the hospital-acquired infection (type number in box)?

12.

Question - Not Required - To the best of your knowledge, the infection started at your... surgical site
respiratory system
intravenous needle insertion site
other wound or skin damage site
catheter insertion site
other site
don't know

*13.

Question - Required - When you or your loved one acquired the infection, the hospital staff and physicians... Provided full information about the source of the problem
Did not provide full information about the source of the problem

14.

Please provide the following basic contact information so that we can call you to find out more about your experience. Your personal story will help us move this issue forward!

Name:

First Required	Last Required

Email: Required

Street 1:

City/State/ZIP:

City Required	State Required	ZIP Required

Country:

Phone Number:

Yes, I would like to receive free periodic consumer updates from Consumers Union Advocacy. (Sí, me gustaría recibir boletines con información del consumidor de Consumers Union.)

Email Format:

*15.

Question - Required - Would you be willing to give us your permission to publish your comments? Even with your permission here, we will not use your information without making a follow up call to you to confirm your information and your permission.

16.

Question - Not Required - Did your health insurance company refuse to pay or deny claims on any expenses associated with your hospital-acquired infection?

17.

Question - Not Required - Do you have additional comments regarding your insurance?

This is not a scientific survey.