Form 6 Chemical Sterilants

MODULE D: Chemical Sterilants Form Approved

7/23/10 OMB No. 10AP-xxxx

Expiration Date: xx/xx/2011

PROGRAMMING INSTRUCTIONS APPEAR IN BLUE.

INTRO QUESTIONS
A.	Did you sterilize medical instruments or supplies using ETHYLENE OXIDE (EtO in the past 7 calendar days)? d isplay calendar highlighting the past 7 calendar days. (APPLIES TO ALL QUESTIONS WITH ‘IN THE PAST 7 CALENDAR DAYS’.		Yes è SUBMODULE 1 No
B.	Did you sterilize medical instruments or supplies using HYDROGEN PEROXIDE GAS PLASMA in the past 7 calendar days?		Yes è SUBMODULE 2 No
QUESTION C IS TO BE COMPLETED BEFORE DISPLAYING SUBMODULEs
C.	From which organization(s) have you achieved professional certification for sterile processing of medical instruments or supplies? Please  all that apply.		International Association of Healthcare Central Service Materiel Management (IAHCSMM) Certification Board for Sterile Processing and Distribution (CBSPD) Other (Please specify): ______________________________ I have not yet achieved professional certification
IF Respondent MARKED ‘YES’ TO INTRO QUESTIONS A AND B, RANDOMIZE ORDER SUBMODULES ARE PRESENTED. IF Respondent MARKed ‘YES’ TO ONLY ONE OF THESE TWO QUESTIONS è go TO APPROPRIATE SUBMODULE.

SUBMODULE 1. ETHYLENE OXIDE (EtO)
	During your career, how long have you been chemically sterilizing medical instruments or supplies using EtO?		Less than one year 1-5 years 6-10 years 11-20 years More than 20 years
	When was the last time you received training on the safe handling of ethylene oxide EtO?		Within the past 12 months More than 12 months ago I never received training
	Are you familiar with the OSHA guidelines for workplace exposure to EtO?		Yes No
If you work for more than one employer, the following questions apply to your primary employer, i.e., the one for which you typically work the most hours. If you are self-employed, consider yourself the employer.
	Does your employer have standard procedures for sterilizing with EtO?		Yes No I don’t know
	During the past 7 calendar days, in which of the following work settings did you sterilize medical instruments or supplies using EtO? Please  all that apply.		Hospital central supply/processing and distribution area Other hospital area Outpatient care center Physician’s office Dental office, clinic or lab Facility that provides sterilized supplies to healthcare providers Other location (Please specify): _____________________________
If only one work setting marked in Question 5 è Go to Question 7.
	Of the locations you checked, please indicate the work setting where you most often sterilized medical instruments or supplies using EtO during the past 7 calendar days.		list work settings marked in Question 5 (USE RADIO BUTTONS).
	During the past 7 calendar days, on how many days did you sterilize medical instruments or supplies with a sterilizer using EtO?		1 day 2 days 3 days 4 days 5 days 6 days 7 days
	During the past 7 calendar days, did you sterilize medical instruments or supplies with an EtO sterilizer that uses compressed-gas cylinders (EtO mixtures) or single-use cartridges of EtO?		Yes No è go to Question 22

EtO Sterilizer with IN-CHAMBER Aeration
	During the past 7 calendar days, did you sterilize medical instruments or supplies using an EtO sterilizer with in-chamber aeration (i.e., load does not need to be transferred after sterilization to a separate aerator)? Note: Check “Not applicable” if your workplace does not have this type of EtO sterilizer.		Yes No è go to Question 15 Not applicable è go to Question 15
	During the past 7 calendar days, what was the total number of loads you processed using an EtO sterilizer with in-chamber aeration?		1 load 2-3 loads 4-5 loads 6-10 loads More than 10 loads
	During the past 7 calendar days, the total number of loads you processed using an EtO sterilizer with in-chamber aeration was…		More than usual Fewer than usual About the same as usual
	What was the source of EtO gas for the sterilizer with in-chamber aeration you used most often during the past 7 calendar days?		Gas cylinder(s) Single-use cartridge (requires cartridge to be inside sterilizer with door closed before it is punctured) ègo to Question 14; skip Questions 28 through 37
	Which best describes the location of the EtO supply gas cylinder for the sterilizer with in-chamber aeration you used most often during the past 7 calendar days?		Gas cylinder(s) located in a different room than the sterilizer. Gas cylinder(s) located in the same room as the sterilizer.
	Considering the EtO sterilizer with in-chamber aeration you used most often during the past 7 calendar days…		Yes	No	I don’t know
	a. …was operational local exhaust ventilation provided above the door of the sterilizer?		¦	¦	¦
	b. …was there a continuous monitor located near the sterilizer that provides a warning when EtO leaks occur?		¦	¦	¦

EtO Sterilizer with SEPARATE Aeration Chamber
	During the past 7 calendar days, did you use an EtO sterilizer with a separate aeration chamber (i.e., load needs to be transferred after sterilization to a separate aerator)? Note: Check “Not applicable” if your workplace does not have this type of EtO sterilizer.		Yes No ègo to Question 22 Not applicable ègo to Question 22
	During the past 7 calendar days, how much time did you typically spend transferring a single load from a sterilizer to the aeration chamber? Note: Include only the time spent transferring the load from the sterilizer to the aeration chamber.		Less than 1 minute 1-2 minutes 3-4 minutes 5-6 minutes More than 6 minutes
.	During the past 7 calendar days, what was the total number of loads transferred from the sterilizer to the aeration chamber?		1 load 2-3 loads 4-5 loads 6-10 loads More than 10 loads
	During the past 7 calendar days, the total number of loads you transferred from the sterilizer to the aeration chamber was…		More loads than usual Fewer loads than usual About the same number of loads as usual
	What was the source of EtO gas for the sterilizer with separate aeration chamber you used most often during the past 7 calendar days?		Gas cylinder(s) Single-use cartridge (requires cartridge to be inside sterilizer with door closed before it is punctured) è GO to Question 21; skip Questions 28 to 37
	Which best describes the location of the EtO supply gas cylinder or container for the sterilizer with a separate aeration chamber you used most often during the past 7 calendar days?		Gas cylinder(s) located in a different room than the sterilizer. Gas cylinder(s) located in the same room as the sterilizer.
	Considering the sterilizer with a separate aeration chamber that you used most often during the past 7 calendar days…..		Yes	No	I don’t know
	a. Was operational local exhaust ventilation provided above the door of the sterilizer?		¦	¦	¦
	b. Was there a continuous monitor located near the sterilizer that provides a warning when EtO leaks occur?		¦	¦	¦

EtO Sterilizer System Using Glass Ampoules of Liquid EtO

During the past 7 calendar days, did you sterilize medical instruments or supplies with a sterilizer system that uses glass ampoules containing liquid ethylene oxide (e.g., Anprolene®)? Note: Check “Not applicable” if your workplace does not have this type of ethylene oxide sterilizer.

Yes No è go to Question 31 Not applicable è go to Question 31

During the past 7 calendar days, what was the total number of loads you processed with this type of sterilizer system?

1 load 2-3 loads 4-5 loads 6-10 loads More than 10 loads

During the past 7 calendar days, the total number of loads you transferred from the sterilizer to the aeration chamber was…

…more loads than usual …fewer loads than usual …about the same number of loads as usual

How often do you place the sealed plastic bag(s) in the sterilizer after breaking the glass ampoule?

Always Sometimes Never

Was the sterilizer system that uses glass ampoules containing liquid EtO connected to an exhaust source?

Yes No I don’t know

Was there a continuous monitor located near this sterilizer system that provides a warning when EtO leaks occur?

Yes No I don’t know

Questions addressing work practices and use of personal protective equipment (PPE) will help us understand what is currently used around EtO sterilizer systems and under what circumstances. Depending on your job and exposures, PPE may not be required.

if respondent marked ‘single-use cartridge’ in Question 12 or question 19, skip questions 28-37. if respondent marked ‘gas cylinder(s)’ in question 12 or question 19, skip questions 28-30.

During the past 7 calendar days, how often did you wear protective gloves while sterilizing medical instruments with this type of sterilizer system?

Always è go to Question 31 Sometimes Never

What were the reasons(s) you did not always wear protective gloves while sterilizing medical instruments or supplies with this type of sterilizer system? Please ü all that apply.

Skin exposure was minimal Not part of our protocol Not provided by employer No one else who does this work uses them Too uncomfortable or difficult to use Not readily available in work area Other (Please specify):______________

if respondent marked only one reason in question 29 and ‘never’ in question 28 è go to Question 31. if respondent marked only one reason in question 29 and marked ‘sometimes’ in question 28 è go to Question 31.

Of the reasons you checked above, please indicate the most important reason you did not always wear protective gloves while sterilizing medical instruments or supplies with this type of sterilizer system.

list reasons marked in question 29 (use radio buttons)

During the past 7 calendar days, did you wear any of the following while using an EtO sterilizer? Please ü all that apply.

Half-facepiece air purifying respirator with chemical cartridge(s)

Full-facepiece air purifying respirator with chemical cartridge(s)

Full-facepiece supplied air respirator

Standard surgical mask

None of above

I don’t know

DISPLAY FOLLOWING NOTE ON A SEPARATE SCREEN (except those who marked ‘I don’t know’): The following questions ask about respirators. standard surgical MASKS ARE NOT respirators. IF Respondent marked ‘HALF-FACEPIECE AIR PURIFYING RESPIRATOR’, ‘full-FACEPIECE AIR PURIFYING RESPIRATOR’OR ‘full-facepiece supplied aIR RESPIRATOR’ in question 31  Go to Question 32 if Respondent marked only ‘standard surgical mask’ or ‘none of the above’ in question 31  Go to Question 33 if respondent marked ‘i don’t know’ in question 31  Go to Question 36

How often did you wear a half- or full –facepiece air purifying respirator with chemical cartridge(s) or a full-facepiece supplied air respirator while using an EtO sterilizer?

Always è go to Question 35 Sometimes

What were the reason(s) you did not always wear a half-facepiece air purifying respirator with chemical cartridge(s), a full-facepiece air purifying respirator with chemical cartridge(s), or a full-facepiece supplied air respirator while using an EtO sterilizer? Please  all that apply.

An engineering control (e.g., ventilated enclosure/ chamber) was being used Exposure was minimal Not part of our protocol Not provided by employer No one else who does this work uses them Too uncomfortable or difficult to use Not readily available in work area Other (Please specify): _______________________________

If R marked more than one reason in Question 33 è Go to Question 34. Otherwise è Go to instructions before Question 35.

Of the reasons you checked above, please indicate the most important reason you did not always wear a respirator while using an EtO sterilizer.

list reasons marked in Question 33 (USE RADIO BUTTONS)

If Respondent marked “half-facepiece air purifying respirator” or “full-facepiece air purifying respirator” in Question 31 è Go to Question 35. If Respondent marked “FULL-facepiece SUPPLIED air respirator” in Question 31 è Go to Question 36. Otherwise è Go to Question 36.

Have you been fit-tested by an occupational health and safety specialist for the respirator(s) you use for EtO sterilization?

Yes No

Has exposure monitoring (using badges or other sampling devices) been conducted in the past 12 months to assess your or your co-workers’ exposure to EtO?

Yes No I don’t know

A medical surveillance program may include work history, physical exam, blood and/or urine tests, etc. Do you participate in a medical surveillance program that addresses potential health effects of exposure to EtO?

Yes No, my (primary) employer offers such a program but I did not participate in it. My (primary) employer does not provide/I am not aware that my employer provides such a program. All responses è if respondent marked ‘yes’ to Question b ègo to submodule 2. otherwise, exit module and go to core module if this is the first hazard module completed. If this is the second hazard module completed, end survey. end with ‘thank you’ statement.

SUBMODULE 2: Hydrogen Peroxide Gas Plasma

	During your career, how long have you been chemically sterilizing medical instruments or supplies using hydrogen peroxide gas plasma?		Less than one year 1-5 years 6-10 years 11-20 years More than 20 years
	When was the last time you received training on the safe handling of hydrogen peroxide gas plasma?		Within the past 12 months More than 12 months ago I never received training
If you work for more than one employer, the following questions apply to your primary employer, i.e., the one for which you typically work the most hours. If you are self-employed, consider yourself the employer.
	Does your employer have standard procedures for sterilizing with hydrogen peroxide gas plasma?		Yes No
	During the past 7 calendar days, in which of the following work settings did you sterilize medical instruments or supplies using hydrogen peroxide gas plasma? Please  all that apply.		Hospital central supply/ processing and distribution area Other hospital area Outpatient care center Physician’s office Dental office, clinic or lab Facility that provides sterilized supplies to healthcare providers Other location (Please specify): _______________________________
If only one work setting marked in Question 41 è Go to Question 43.
	Of the locations you checked above, please indicate the work setting where you most often used hydrogen peroxide gas plasma during the past 7 calendar days.		list LOCATIONS marked in Question 41 (use radio buttons)
	During the past 7 calendar days, on how many days did you sterilize medical instruments or supplies with a sterilizer using hydrogen peroxide gas plasma?		1 day 2 days 3 days 4 days 5 days 6 days 7 days
	During the past 7 calendar days, what was the total number of loads you sterilized using hydrogen peroxide gas plasma?		Fewer than 11 loads 11-20 loads 21-50 loads 51-100 loads More than 100 loads
	During the past 7 calendar days, the total number of loads you transferred from the sterilizer to the aeration chamber was…		…more loads than usual …fewer loads than usual …about the same number of loads as usual All responses è if respondent marked ‘yes’ to Question A ègo to submodule 1. otherwise, exit module and go to core module if this is the first hazard module completed. If this is the second hazard module completed, end survey. end with ‘thank you’ statement.

Thank you for participating in the NIOSH Health and Safety Practices Survey of Healthcare Workers. Your answers have been submitted.

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