Ambulatory Care Facilities

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Form Approved
OMB No. 0920-xxxx
Exp. xx/xx/xxxx

ASSESSMENT OF OCCUPATIONAL EXPOSURES TO BLOODBORNE PATHOGENS:
AMBULATORY SURGERY CENTERS
Please give this survey to the one person in your facility who is most knowledgeable about management of
occupational exposure to blood/body fluids.
Do not return a photocopy of this survey. Our electronic scanners can only read this original survey. You may retain
photocopies for your own records.
Please use the enclosed envelope to return the completed survey to:
NRC+Picker
Survey Processing Center
PO Box 82660
Lincoln, NE 68501-9465
1-800-733-6714

Definitions of Terms
HCV: Hepatitis C Virus
HBV: Hepatitis B Virus
HIV: Human Immunodeficiency Virus
PEP: Postexposure Prophylaxis
Percutaneous exposure: Exposure by penetration of the skin by a needle or other sharp object that
was in contact with blood, tissue, or other body fluid before the exposure
Mucosal exposure: Mucous membrane exposure to blood, tissue, or other body fluid for example,
through the eyes or mouth
Cutaneous exposure: Exposure to blood, tissue, or other body fluid through breaks in the skin, for
example, scratches, abrasions, burns, or other lesions
Sharp: Any device or object having corners, edges, or projections capable of cutting or piercing the
skin (e.g., a needle, scalpel, bone fragment, etc.)
Healthcare worker: This includes but is not limited to full-time staff, part-time staff, professional
staff, students, and volunteers.

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Public reporting burden of this collection of information is estimated to average 20 minutes per response, including the time for reviewing
instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of
information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a
currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including
suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN:
PRA (0920-xxxx).

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The following questions address facility
awareness and preparation:

5. During what hours are occupational exposure
management services available from an off-site
contractor? (Mark all that apply.)
E Weekdays (M-F) daytime
E Weekdays (M-F) nights
E Weekend daytime
E Weekend nights
E Holidays
E Not Applicable

1. Does your facility have written policies and
procedures for on-the-job exposure to blood/body
fluids?
E Yes
E No (Go to #3)
E Do not know (Go to #3)

2. How often are the policies and procedures reviewed
and updated?
E Quarterly
E Semi-annually
E Annually
E As new recommendations or
handling/management procedures are
known
E Do not know

The next questions address general
occupational exposure management practices
at your facility:

3. Do healthcare workers at your facility have access
to occupational exposure management services?
E Yes
E No

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4. During what hours are occupational exposure
management services available at your facility?
(Mark all that apply.)
E Weekdays (M-F) daytime
E Weekdays (M-F) nights
E Weekend daytime
E Weekend nights
E Holidays
E Not available at my facility/organization.

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6. During what hours are occupational exposure
management services available at another facility in
your healthcare system? (Mark all that apply.)
E Weekdays (M-F) daytime
E Weekdays (M-F) nights
E Weekend daytime
E Weekend nights
E Holidays
E Not Applicable

The following questions are about
occupational exposures to HBV, HCV and HIV:

7. During the past 12 months, how many occupational
exposures to HBV were reported at your facility?
E 0 (Go to #10)
E 1-5
E 6 - 10
E 11 - 15
E 16 - 20
E 20+
E Do not know (Go to #10)

8. Does your facility provide hepatitis B vaccine to
your healthcare workers?
E Yes
E No (Go to #10)
E Do not know (Go to #10)

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9. When hepatitis B vaccine is administered, is the
worker tested for anti-HBs 1 - 2 months after
completion of the vaccine series?
E Yes
E No
E Do not know

These next questions are regarding PEP
(postexposure prophylaxis) policies and
procedures:

14. Does your facility provide counseling about risk of
infection, PEP adverse events, and their
management to exposed healthcare workers after
occupational exposures?
E Yes
E No

10. During the past 12 months, how many occupational
exposures to HCV were reported at your facility?
E 0
E 1-5
E 6 - 10
E 11 - 15
E 16 - 20
E 20+
E Do not know

15. The type of hepatitis B PEP that is administered is
based on the source patient infection status, the
exposed worker hepatitis B vaccine status and
hepatitis B susceptibility. Do you provide hepatitis B
PEP (i.e., hepatitis B vaccine and/or hepatitis B
immune globulin) after occupational exposures?
E Yes
E No
E Do not know

11. During the past 12 months, how many occupational
exposures to HIV were reported at your facility?
E 0 (Go to #14)
E 1-5
E 6 - 10
E 11 - 15
E 16 - 20
E 20+ (Go to #14)
E Do not know

16. Are healthcare workers provided PEP for HIV
exposure?
E Yes
E No
E Do not know

12. If the HIV status of a patient involved in an
occupational exposure was unknown, how often was
a test performed to determine HIV status?
E Never
E Sometimes
E Usually
E Always
E No exposures in last 12 months

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13. How often does your facility use rapid HIV testing
for source patients involved in an occupational
exposure? (A rapid HIV test provides results in
about 20 minutes.)
E Never
E Sometimes
E Usually
E Always

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17. There are several drug regimens available that may
be selected as HIV PEP. Has your facility selected
an initial primary PEP drug regimen(s)?
E Yes
E No
E Do not know

18. Are HIV PEP medications readily available (for
example, within 4 hours)?
E Yes, at our organization
E Yes, at a third-party contractor
E Yes, through a local pharmacy
E No
E Do not know
E Yes, other (specify) ____________

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19. Please estimate the percentage of workers starting
HIV PEP within 2 hours after an occupational
exposure.
E 0%
E 1 - 10%
E 11 - 25%
E 26 - 50%
E 51 - 75%
E 76 - 100%

Now we have a couple of questions about
exposure prevention measures:

20. For those workers who take HIV PEP, please
estimate the percentage who take PEP for 28 days.
E 0%
E 1 - 10%
E 11 - 25%
E 26 - 50%
E 51 - 75%
E 76 - 100%

24. At what interval is additional training about
bloodborne pathogens provided?
E Every year
E Every two years
E Only when new information is available
E Other (specify) _____________

23. Do healthcare workers receive training about
avoiding exposure to bloodborne pathogens at the
beginning of their employment?
E Yes
E No

About your facility/organization:
21. After exposure, what type(s) of monitoring is
conducted for healthcare workers? (Mark all that
apply.)
E Do not know
E None
E Laboratory monitoring of PEP toxicity
E Laboratory monitoring of seroconversion
E Other (specify) _____________

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22. If serologic testing is performed for HIV, what is the
schedule of testing?
E Baseline, 6 weeks, 3 months, 6 months after
exposure
E Baseline, 6 weeks, 3 months, 6 months, 12
months after exposure
E Baseline, and other schedule (specify)
____________________________

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25. Approximately how many surgical procedures were
performed at your facility in 2005?
E Less than 500
E 500 - 999
E 1000 - 4999
E 5000 - 9999
E 10,000 - 15,000
E More than 15,000

26. What is the total number of healthcare workers at
your facility?
E Less than 100
E 100 - 500
E 501 - 2000
E 2001 - 4000
E More than 4000

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27. Please estimate the percentage of healthcare
workers at your facility who are regularly (daily) at
risk for occupational exposure to blood/body fluids.
E 0
E 1% - 25%
E 26% - 50%
E 51% - 75%
E 75% - 100%

Thank you for completing this survey!
Copyright NRC+Picker 2006, All Rights Reserved

28. What best describes the title of the person who
oversees occupational exposure management?
E Infectious disease physician
E Emergency department physician
E Occupational health physician
E Occupational health nurse
E Other (specify) __________________

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29. Do you have any comments you would like to
share concerning occupational exposure
management practices or this survey?

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