Facility ID#:
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*HCW ID#:
| Social Security #:
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Secondary ID#:
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HCW Name, Last: First: Middle:
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Street Address:
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City: State: Zip Code:
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Home Phone: ( )
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Email Address:
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*Gender: F M Other *Date of Birth: / /
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Born in U.S.? Yes No Unknown
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Ethnicity: Hispanic or Latino
Not Hispanic or Not Latino
| Race: American Indian or Alaska Native
Asian Black or African American Native Hawaiian or Other Pacific Islander White
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Employment Information
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Work Phone: ( )
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*Start Date: / /
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*Work Status: Active Inactive No longer affiliated
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*Type of employee: Full-time Part-time Contract employee Volunteer Other (specify)_________
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*Work Location: Department: Supervisor:
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*Occupation: Title:
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If occupation is a physician, indicate clinical specialty (check one):
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ANE – Anesthesiology CAR – Cardiology CTS – Cardiothoracic Surgery CRC – Critical Care DOS – Dentistry/Oral Surgery DER – Dermatology ENT – Ear, Nose and Throat ERM – Emergency Medicine FAP – Family Practice GAS – Gastroenterology GEN – General Surgery/Trauma IND – Infectious Diseases INM – Internal Medicine MSU – Other Medical Subspecialty NEP – Nephrology NEU – Neurology
| NRS – Neurosurgery OBG – Obstetrics and Gynecology OPT - Ophthalmology ORT – Orthopedics OSS – Other Surgical Specialty OTH – Other Clinical Specialty PAT – Pathology PED – Pediatrics PLS – Plastic Surgery PMR – Physical Medicine/Rehab PSC – Psychiatry PUL – Pulmonology RAD – Radiology URO – Urology VAS – Vascular Surgery
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Performs direct patient care (i.e., hands on, face-to-face contact with patients for the purpose of diagnosis, treatment and/or monitoring): Yes No
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Assurance of Confidentiality: The voluntarily provided information obtained in this surveillance system that would permit identification of any individual or institution is collected with a guarantee that it will be held in strict confidence, will be used only for the purposes stated, and will not otherwise be disclosed or released without the consent of the individual, or the institution in accordance with Sections 304, 306 and 308(d) of the Public Health Service Act (42 USC 242b, 242k, and 242m(d)).
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, Reports Clearance Officer, 1600 Clifton Rd., MS D-74, Atlanta, GA 30333, ATTN: PRA (0920-0666).
CDC 57.204 (Front), v6.4
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