Form 0920-15CN Attachment M_Health Facility Assessment and Case Finding

2014 Emergency Response to Ebola in West Africa: Data Collection for Assisting Foreign and International Entities to Conduct Public Health Activities

Attachment M_Health Facility Assessment and Case Finding Survey

Health Facility Assessment and Case Finding Survey

OMB: 0920-1033

Document [docx]
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OMB Approved

0920-XXXX

Expiration Date xx/xx/xxxx


Health Facility Name: _________________ Initials of Interviewer: _________________


Health Facility Assessment and Case Finding Survey

Instructions: Ask to interview the supervising health care worker present at the time of your visit.

My name is ______and I am here on behalf of the [Ministry of Health]. We are working to understand the capacity and needs of health care facilities related to the Ebola response. I will be asking you a few questions about your health facility, as well as the details of any suspect, probable, or confirmed Ebola cases seen at your facility in the last three weeks. The interview should take about 30 minutes, and you are free to skip any questions you do not know the answer to. Do you have any questions?

Date of interview:




Day XX Mon XXX Year XX


Geographic information for the health facility

County / District / Prefecture:______________________


Community / Village / Zone:_________________________


Other geographic information:________________________


FACILITY INFORMATION


Name of HCW being interviewed: ___________________________ Phone number: ________________


HCW position:______________________________________


Approximate number of medical staff (nurses, doctors, etc):________________


Approximate number of non-medical staff (cleaners, security, etc):_______________


Approximate number of beds (if inpatient hospital):___________________


Approximate number of visits per month (if outpatient clinic):__________________


Approximate number of admissions per month (if inpatient ward): _________________



Training

When was the most recent Ebola-specific training at your facility? ___________________

Who provided this training? _________________________________________________



FACILITY EBOLA RESPONSE PLAN


If an acutely ill patient presented to your facility today and your staff had high concern for Ebola infection, what would be your facility’s procedure? I’m going to ask some specific questions:


Who would you call to report the case? (be specific; HCW can give multiple answers) _________________________________________________________________________________________


Where would you place the patient in your facility? (be specific)

________________________________________________________________________________________


In your opinion, would the staff here have adequate PPE available?

Yes___ No____ If no: what is lacking?:_______________________________________________


In your opinion, does your staff have adequate training to use that PPE appropriately?

Yes___ No_____ If no: what is lacking?:_______________________________________________


In your opinion, does your clinic have adequate materials for disinfection and cleaning?

Yes___ No_____ If no, what is lacking?: ______________________________________________


Would someone from your facility collect a lab sample on the patient?

Yes______ If yes, did that person have Ebola-specific training? Yes ______ No_______

No ______ If no, how would a lab sample be collected?___________________________________


Would you transfer the patient to another facility?

Yes, as soon as it can be arranged_____

Yes, if a positive test result is received________

No_______

Other:______________________________________________________________


If you would transfer the patient, to where/which facility?:_________________________



Supplies

Has your facility received additional PPE for treating potential Ebola patients? Yes_____ No_____

If yes, from whom:_________________________



Can you demonstrate how you would prepare to dress and undress to see a patient suspected of having Ebola? (describe demonstration)





Right now, does your facility have available:

Gloves

Yes

No


Thermometer that can be used on a single suspect Ebola case-patient then discarded

Yes

No

Disposable gowns

Yes

No


Stethoscope that can be used on a single suspect Ebola case-patient then discarded

Yes

No

Respirators/masks

Yes

No


IV fluids and tubing

Yes

No

Face shields or goggles (eye protection)

Yes

No


Chlorine

Yes

No

Boots or foot protection

Yes

No


20 L buckets

Yes

No

Single use gowns

Yes

No


Rubber boots

Yes

No

Plastic apron

Yes

No


Disposable mask

Yes

No

Goggles

Yes

No


Head cover

Yes

No

Plastic garbage bags

Yes

No


Plastic basin for hand washing after consultation

Yes

No

Body bag

Yes

No


Case definitions posted

Yes

No

Chlorine sprayer of 1 litre capacity

Yes

No


Information and sensitization material

Yes

No

Sponge

Yes

No


Sharps box (or modified drug pot)

Yes

No

Formula for preparation of chlorine solution written or described

Yes

No





Data and Communication

Does your facility have a computer available? Yes_____ No_____

Does your facility have internet access available? Yes_____ No_______

Is your facility in an area that generally has good cell phone reception? Yes_______ No____________

EBOLA CASES AT FACILITY

Has this facility seen any suspect, probable, or confirmed cases of Ebola in the last three weeks? (use a calendar to define the time frame for the HCW)

Yes:_____

No:_____ If no, skip to the next page




Shape1

Patient’s Name: _______________________

Origin: Community / Village / Zone : __________________ County / District / Prefecture:_________________­


DOB :




Age:


Gender:

M

F

(Day XX Mon XXX Year XX) (years)


Date of symptom onset:




Date of presentation to the Health Facility:




(Day XX Mon XXX Year XX) (Day XX Mon XXX Year XX)

Date case reported to Ministry:




Method of reporting case/who did you call:


(Day XX Mon XXX Year XX)


Lab results (circle one):

Positive

Negative

No lab sample obtained*

Lab sample obtained, but no results reported

*If no lab sample obtained why not?

Method of receiving lab results (circle all that apply):

Received call

Received email

Receive text

Receive written report


Patient outcome:

Admitted:

Yes

No

If yes, where:_____________________

Transferred:

Yes

No

If yes, where:________________AND Who transferred the patient: _____________

Died:

Yes

No

If yes, date of death:_______ AND date of burial:_____________


If yes died, who conducted the burial? _____________________

Other:

(explain):____________________________________________________________________



Any contact tracing conducted for this case (that you are aware of):

Yes

No

Unknown


Comments:









Has any contact tracing related to this case been done?

: Yes No Unknown

Comments:





Public reporting burden of this collection of information is estimated to average 30 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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