Acute Care Facilities

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

ASSESSMENT OF OCCUPATIONAL EXPOSURES TO BLOODBORNE PATHOGENS:
ACUTE CARE FACILITIES
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:

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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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

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

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

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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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%

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) _____________

About your facility/organization:
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%

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) _____________

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)
____________________________

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

25. Please choose the category that describes your hospital.
E Public
E Private, Non-profit
E Proprietary

26. Please choose the description that best applies to your
facility.
E Rural
E Urban, Non-teaching
E Urban, Teaching

27. What is the bed size of your hospital?
E 1 - 99
E 100 - 199
E 200 - 299
E 300 - 399
E 400 - 499
E 500+

28. How many patients were discharged from your hospital in
2005?
E Less than 500
E 500 - 4999
E 5000 - 9999
E 10,000 - 19,999
E 20,000 - 30,000
E 30,000 - 40,000
E 40,000 - 49,999
E 50,000+

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

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29. 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

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

30. 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%

31. 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) __________________
Thank you for completing this survey!

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Copyright NRC+Picker 2006, All Rights Reserved

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