BBP Exposure Control Plan Survery

Attachment D: Survey Instrument

Form Approved

OMB No. 0920-xxxx

Exp. Date xx/xx/20xx

1. How would you describe your primary dental practice? (If you work at more than one practice, please refer to the practice where you perform the most services in this and subsequent questions.)

 Private, dentist-owned practice that is not incorporated or franchised

 Private, incorporated practice

 Private, franchised practice

 Private, partnership

 In a dental school, private/public hospital, government facility (e.g., military, VA, his) or public health (e.g., FQHC, non-profit clinic) [SKIP TO INELIGIBLE EXIT MESSAGE]

 I don’t know [SKIP TO INELIGIBLE EXIT MESSAGE]

 Other, please specify: ________________________

2. What is the role of the person completing this survey?

 Retired or not currently in clinical practice [SKIP TO INELIGIBLE EXIT MESSAGE]

 Dentist owner of the practice (sole proprietor or partner)

 Dentist non-owner in the practice

 Dental hygienist

 Dental assistant or other staff providing chairside assistance at least 50% time

 Front office or clerical staff providing none or less than 50% time on chairside assistance

 Other

3. Does the practice currently have a person responsible for OSHA compliance?

 Yes, I am the person responsible for OSHA compliance [SKIP TO Q4]

 Yes, another staff member is responsible for OSHA compliance

 No, we do not have a person responsible for OSHA compliance [SKIP TO Q4]

 I don’t know [SKIP TO Q4]

3a. If you are not responsible for OSHA compliance at the practice, what type of staff member is responsible?

 Dentist

 Dental hygienist

 Dental assistant or other staff providing chairside assistance at least 50% time

 Front office or clerical staff providing none or less than 50% time on chairside assistance

 Other

Public reporting burden of this collection of information is estimated to average 15 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 Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-xxxx).

4. Including yourself, how many staff members (full-time or part-time) currently work in the practice?

	none	1	2-4	5-10	>10	Don’t Know
General dentist						
Specialist dentist						
Dental hygienist						
Dental assistant or other staff providing chairside assistance at least 50% time						
Front office or clerical staff providing none or less than 50% time on chairside assistance						
Other						

5. Does the practice currently have a written Exposure Control Plan to eliminate or minimize occupational exposures to blood and other potentially infectious materials (including saliva and other body fluids)?

 Yes [SKIP TO Q6]

 No

 We refer to a published plan if needed but don’t have our own written plan

 I don’t know

5a. Is the practice planning to implement an Exposure Control Plan in the next 12 months?

 Yes, we have a plan in progress to implement an Exposure Control Plan

 No, our practice does not have any plans for an Exposure Control Plan

 I don’t know

5b. Prior to this survey, was the practice aware of the requirement in the OSHA Bloodborne Pathogens standard to have an Exposure Control Plan for blood and other potentially infectious materials?

 Yes, we were aware of the OSHA Exposure Control Plan requirement [SKIP TO Q10]

 No, we were not aware of any OSHA Exposure Control Plan requirement [SKIP TO Q10]

 I don’t know [SKIP TO Q10]

6. How was the current Exposure Control Plan at the practice developed?

 By our dental practice, using the OSHA template as a basis

 By our dental practice, without the OSHA template

 Purchased from a commercial vendor

 Purchased or acquired from a professional organization

 Other

 It was in place before I was hired

 I don’t know

6a. Was the Exposure Control Plan at the practice…

	Yes	No	Don’t Know
Developed with the help of a consultant or consulting firm?			
Customized for your practice?			

7. Did the practice review or make changes to your Exposure Control Plan within the past 12 months?

 Yes, we reviewed and made changes to our plan within the past 12 months

 Yes, we reviewed but did not make any changes to our plan within the past 12 months

 No, we have not reviewed or made changes to our plan within the past 12 months [SKIP TO Q8]

 I don’t know [SKIP TO Q8]

7a. Who participated in reviewing or making changes to the practice’s Exposure Control Plan within the past 12 months? (check all that apply)

 OSHA Compliance Officer

 Dentist(s)

 Dental hygienist(s)

 Dental assistant(s) or other staff providing chairside assistance at least 50% time

 Front office or clerical staff providing none or less than 50% time on chairside assistance

 Outside consultant

 Other

8. Other than updating or making changes to your Exposure Control Plan, has the practice used or consulted your Exposure Control Plan within the past 12 months?

 Yes

 No [SKIP TO Q9]

 I don’t know [SKIP TO Q9]

8a. For what reason(s) has the practice used or consulted your Exposure Control Plan within the past 12 months? (check all that apply)

 To train staff member(s)

 For guidance on techniques to reduce staff members’ exposure to blood or body fluids

 To record and respond to a specific exposure incident (e.g., needle stick)

 Other

For the following questions, staff with occupational exposure are all those who could reasonably come into contact with blood or other potentially infectious materials (including saliva, other body fluids, and unfixed tissue or organs) as part of their job duties, not only those who have experienced known exposure incidents. Contact can include skin, eye, mucous membrane, or parenteral contact.

9. Does the Exposure Control Plan at the practice have any of the following elements?

	Yes	No	Don’t Know
Lists
List of all job classifications in which all or some employees have potential occupational exposure to blood and other potentially infectious materials			
List of all tasks and procedures, performed by the above employees, in which occupational exposure potentially occurs			
Methods to reduce the likelihood of exposure
Universal (standard) precautions			
Engineering and work practice controls			
Personal protective equipment			
Housekeeping controls (cleaning, decontamination, storage, laundry, waste handling, etc.)			
Pre/post-exposure medical care
Hepatitis B vaccination for employees with occupational exposure			
Post-exposure evaluation and follow-up for staff exposed to blood or other potentially infectious materials			
Process for testing of source patient			
Hazard communications
Using labels and signs to communicate hazards to staff			
Information and training for staff with occupational exposure			
Record-keeping Personnel medical records for post-exposure evaluation			
Personnel medical records related to Hepatitis B vaccination			
Records of training staff on the Exposure Control Plan			
Sharps injury log			

If you answered “yes” to all of the elements of the above question, skip the following question. If you answered “no” to any of the above elements, please complete the following question.

10. How strongly do you agree with each of the following endings to this statement?

The practice does not have an Exposure Control Plan, or we have an Exposure Control Plan that does not have all of the elements listed above, because…”

	Strongly agree	Somewhat agree	Somewhat disagree	Strongly disagree	Don’t Know
Cost					
Lack of time					
Lack of expertise					
Staff are resistant					
Not required by law					
Do not apply to our dental practice					
Too complex					
Not specific enough					
Not clearly written					
Conflict with Occupational Health and Safety regulations in our state					

11. Does the practice currently use any of the following engineering controls?

	Yes, currently in use	No, evaluated but not used	No, not evaluated or used	Don’t Know
Safety scalpel				
Safety aspirating syringe / retractable needle				
Self-sheathing needle				
Needleless systems				
Sharps disposal containers				

If you answered “yes” to all of the above engineering controls, please skip the following question. If you answered “no” to any of the above, please complete the following question.

11a. How strongly do you agree with each of the following endings to this statement?

The practice does not currently have one or more of the above engineering or work practice controls because…” (Check all that apply)

	Strongly agree	Somewhat agree	Somewhat disagree	Strongly disagree	Don’t Know	I
Had no need for the device					
Not safer than our existing methods					
No standards to compare its safety to other devices					
Difficult to use					
Not reliable					
Financial cost					
Did not realize use of safety devices was required					

12. The practice currently…

	Yes	No	Don’t Know
Provides readily accessible handwashing facilities			
Offers antiseptic hand cleanser/towelettes if handwashing facilities are not available			
Requires that staff wash hands or skin with soap and water immediately after hand or skin contact with blood or other potentially infectious materials			
Requires that staff flush mucous membranes with water immediately after mucous membrane contact with blood or other potentially infectious materials			
Does not allow any bending, recapping, or removing contaminated needles/sharps except with use of mechanical device or one-handed technique, and only when no alternative is feasible or the action is required by a specific dental procedure			
Does not allow eating, drinking, smoking, applying cosmetics or lip balm, or handling contact lenses in work areas with potential occupational exposure			
Does not allow storing food and drink in locations where blood or other potentially infectious materials are present			
Minimizes splashing, spraying, spattering and generation of droplets during procedures involving blood or other potentially infectious materials			
Ensures leak-proof, puncture-proof, and labeled storage, transport, and shipment of blood or other potentially infectious material			

13. Does the practice provide personal protective equipment to staff with occupational exposure to blood or other potentially infectious materials?

 Yes

 No [SKIP TO Q14]

 I don’t know [SKIP TO Q14]

13a. What types of personal protective equipment does the practice provide? (check all that apply)

 Gloves

 Protective body clothing (e.g., gowns, aprons, laboratory coats, clinic jackets)

 Surgical caps or hoods

 Shoe covers

 Face shields

 Surgical masks

 Respirator (e.g., N95)

 Eye protection (e.g., goggles, glasses with solid side shields)

 Other

14. Does the practice offer Hepatitis B virus (HBV) vaccination to newly-hired staff with potential occupational exposure to blood, body fluids, or other potentially infectious materials?

 Yes

 No

 I don’t know

15. Have any staff members at the practice experienced one or more known exposure incidents, including sharps injuries, performing work duties in the past 12 months?

(An exposure incident is eye, mouth, other mucous membrane, non-intact skin, or parental contact with blood or other potentially infectious materials, including saliva, other human body fluids, unfixed human tissue or organ, and HIV or HBV cultures. It includes injuries from sharps that are potentially contaminated, even if contamination status is unknown.)

 Yes

 No [SKIP TO Q19]

 I don’t know [SKIP TO Q19]

16. After the incident(s) occurred, what steps did your dental practice take? (check all that apply)

 Applied First Aid

 Documented circumstances of exposure incident

 Directed exposed individual to a qualified healthcare professional with documentation

 Arranged for source patient testing, if the source patient was known and consented

 Paid for post-exposure evaluation and, if indicated, prophylaxis

 Other

17. Did any exposure incidents among staff members at the practice in the past 12 months involve a percutaneous injury from a contaminated sharp, that is, from a sharp instrument or needle that had been used on a patient, (a.k.a., “sharps injury” or “needlestick”)?

 Yes

 No [SKIP TO Q18]

 I don’t know [SKIP TO Q18]

17a. Were incident reports filled out for these exposures?

 Always

 Sometimes

 Never

 I don’t know

18. Did any exposure incidents among staff members in the practice in the past 12 months involve non-sharps exposure to blood or other potentially infectious materials (e.g., saliva, other human body fluids, or unfixed tissue)?

 Yes

 No

 I don’t know

19. Does the practice provide training on your Exposure Control Plan to employees at risk of potential occupational exposure to blood or body fluids?

 Yes

 No [SKIP TO Q20]

 We do not have an Exposure Control Plan [SKIP TO Q20]

 I don’t know [SKIP TO Q20]

19a. When does the practice provide its Exposure Control Plan training to employees at risk of potential occupational exposure to blood or body fluids?

	Yes	No	Don’t Know
Before working with patients			
Soon after hire, for employees with potential for occupational exposure			
Annually, for employees with potential for occupational exposure			
Periodic refreshers			

19b. How does the practice provide training about occupational exposure to blood and other potentially infectious materials? (check all that apply)

 One person attends an OSHA presentation about this topic and trains others in the practice

 Eligible workers attend an OSHA presentation off-site

 Our practice develops and provides the training ourselves

 An outside consultant provides training for our staff

 We use electronic materials for training (e.g., online training module or CD/DVD)

 Other

20. In the past 2 years, have you or other staff members at the practice received any Continuing Education (CE) credit for any courses, workshops, or tests on the OSHA bloodborne pathogens standard?

	Yes	No	Not eligible for CE credits	Don’t Know
You				
Other staff				

21. Does the practice offer its staff any informational materials that address the OSHA bloodborne pathogens standard in the dental setting?

 Yes

 No [SKIP TO Q22]

 I don’t know [SKIP TO Q22]

21a. Which of the following informational materials addressing this standard does the practice provide?

	Yes	No	Don’t know
Videos/CDs/DVDs			
Patient education materials			
Posters			

22. Would the practice be likely to turn to any of the following sources if you needed up-to-date information on methods or procedures to prevent exposures to blood or other potentially infectious materials?

	Yes	No	Don’t Know
American Dental Assistants Association (ADAA)			
American Dental Association (ADA)			
American Dental Hygienist’s Association (ADHA)			
Area Health Education Center (AHEC)			
Association for Professionals in Infection Control and Epidemiology (APIC)			
Centers for Disease Control and Prevention (CDC)			
Dental supply company representative			
Dental teaching institute (dental, dental hygiene, or dental assistant school)			
Infectious Diseases Society of America (IDSA)			
Internet search			
National Institute for Occupational History and Health (NIOSH)			
State or local dental, dental hygiene or dental assisting society			
Occupational Safety and Health Administration (OSHA)			
Organization for Safety, Asepsis and Prevention (OSAP)			
State Occupational Safety and Health agency			

So that we can know more about your practice setting, please answer the following questions about the practice.

23. In which U.S. state is the practice located?

[use the following drop-down list of all US states]

24. Where is the practice located?

 Large city (more than 100,000 people)

 Medium city, could be in rural area (between 50,000 and 100,000 people)

 Small city or a non-rural town that is not a suburb (between 2,500 and 50,000 people)

 Suburb (developed area adjacent to city)

 Rural (area outside cities, generally characterized by farms, ranches, non-suburban small towns with fewer than 10,000 people, and unpopulated regions)

 I don’t know

25. If the practice has any dental specialists, which of the following ADA recognized specialties are represented? (check all that apply)

 No specialists

 Oral and maxillofacial surgery

 Endodontics

 Orthodontics and dentofacial orthopedics

 Pediatric dentistry

 Periodontics

 Prosthodontics

 Oral and maxillofacial pathology

 Oral and maxillofacial radiology

26. Did other staff members in the practice help provide answers for this survey?

 Yes

 No [SKIP TO END]

26a. Which other staff members helped with this survey? (check all that apply)

 Dentist(s)

 Dental hygienist(s)

 Dental assistant(s)

 Front office or clerical staff not providing direct patient care

 Other

Thank you!