Class of 2006 Abstract / Objectives: To develop and evaluate a data collection form that could be used to assess the influence of heparin administration on the septic severity index score in patients with Candida blood stream infections. Methods: A data collection form was developed to evaluate the influence of heparin administration on the septic severity index score in patients with Candida blood stream infections. This form was assessed using rating scales for ease of use, applicability of data collection items and availability of data in charts. Results: Data from 10 patient charts was used to assess the instrument. Patient demographics were similar. The strengths of the form included applicability of 9 out of 10 items in the instrument. Four out of 10 items were rated low for ease of use. In addition, 7 out of 10 pertinent data items were not documented in the charts. Conclusion: An extensive reworking of the data collection form as described in the discussion section was required. The form is ready to be implemented if the proposed study should be performed.