0920-1033 Att B1 HCW.EVD.expriskreport_WestAfrica v10 Eng Translat

Form Approved

OMB No. 0920-1033

Exp. Date 04/30/2015

Local identification number _________________

National identification number _________________

WHO LOGO

CDC LOGO

Health Care Workers (HCWs) and Ebola Virus Disease (EVD) Exposure Risk:

Reporting form to be completed for EVD cases in HCWs

Date completed: (dd/mm/yy) __ __ / __ __ / __ __

Case classification: __ Suspect __ Probable __ Confirmed

Date of onset of symptoms: (dd/mm/yy) __ __ / __ __ / __ __

21 days before date of onset of symptoms: (dd/mm/yy) __ __ / __ __ / __ __

Hello, my name is (first and last name) ____________________ and I work in the response against Ebola. We are asking questions to health care workers to better understand how you were infected and your risk factors. This is to try to stop transmission to other health care workers. If you feel tired at any time, let me know and we can stop. It does not matter if you do not remember details, but tells us the details you do remember. The information we collect is confidential. Any analysis will not contain your name.

May we ask you some questions about the way in which you may have become sick?

Verbal consent obtained: ___ Yes ___ No

If you become too ill to answer our questions, who among your family and colleagues can help us answer some of these questions?

Name of family member: ____________________________ Telephone number: _______________

Name of colleague: _________________________________ Telephone number: _______________

Patient identity

Last name: ________________________ First Name: ______________________ Sex: __ M __ F

Age (years): _______________________ Permanent residence city or village: ____________________

Neighborhood: ____________________ Permanent residence prefecture: ______________________

Country: _________________________ HCW Telephone number: ____________________________

Patient occupation (select a response and provide details as necessary)

❏ Doctor ❏ Red Cross volunteer ❏ Community health worker

❏ Nurse ❏ Traditional healer ❏ Morgue / burial staff

❏ Laboratory staff ❏ Caretaker

❏ Ambulance driver ❏ Midwife

❏ Other (specify): _____________________________________________________________________

Comment: ____________________________________________________________________________

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 Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-1033).

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 Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-1033).

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 Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-1033).

Local identification number _________________

1. What is the name of the health facility where you worked primarily in the 21 days before you became ill? __________________________________________________________________________

If no name, what is the neighborhood / locality? ________________ Chief of Medicine: _____________

2. What type of health facility?

❏ Public hospital ❏ Ebola Treatment Unit (ETU)

❏ Private hospital ❏ Transit center

❏ Laboratory ❏ Community Treatment Center

❏ Clinic / Private practice ❏ Community Transit Center

❏ Health center ❏ None

❏ Health post ❏ Other (specify): _____________________________

3. In which services have you worked in this health facility? (check all that apply):

❏ Emergency ❏ Morgue ❏ Blood bank

❏ Laboratory ❏ Maternity ❏ Other (specify):

❏ Medicine ❏ Pediatrics ____________________________

❏ General care ❏ Suspected case unit

❏ Surgery ❏ Confirmed case unit

4. What is the name of the health facility in which you worked outside your primary work in the 21 days before you became ill? ____________________________________________________________

If no name, what is the neighborhood / locality? ________________ Chief of Medicine: _____________

❏ Did not work in other place (Go to Question 8)

5. What type of health facility?

❏ Public hospital ❏ Ebola Treatment Unit (ETU)

❏ Private hospital ❏ Transit center

❏ Laboratory ❏ Community Treatment Center

❏ Clinic / Private practice ❏ Community Transit Center

❏ Health center ❏ None

❏ Health post ❏ Other (specify): _____________________________

6. In which services have you worked in this health facility? (check all that apply):

❏ Emergency ❏ Morgue ❏ Blood bank

❏ Laboratory ❏ Maternity ❏ Other (specify):

❏ Medicine ❏ Pediatrics ____________________________

❏ General care ❏ Suspected case unit

❏ Surgery ❏ Confirmed case unit

7. Have you worked in another health workplace or provided other services (paid or volunteer) in the 21 days before you became ill? (List all): ______________________________________________________

____________________________________________________________________________________

❏ No other workplace

8. What was the last date that you worked? (dd/mm/yy): __ __ / __ __ / __ __

Local identification number _________________

9. In the 21 days before you became ill, did you (check all that apply):

Provide general patient care ❏ Yes ❏ No

Feed a patient or administer oral medications ❏ Yes ❏ No

Bath or clean patients ❏ Yes ❏ No

Transport patients ❏ Yes ❏ No

Give injections ❏ Yes ❏ No

Draw blood or perform a fingerstick ❏ Yes ❏ No

Recap a needle ❏ Yes ❏ No

Discard sharps ❏ Yes ❏ No

Clean a needle for re-use ❏ Yes ❏ No

Put in an IV ❏ Yes ❏ No

Handle an IV line (e.g., give IV medications) ❏ Yes ❏ No

Handle a urinary catheter ❏ Yes ❏ No

Clean a blood spill ❏ Yes ❏ No

Clean a patient's room ❏ Yes ❏ No

Handle waste ❏ Yes ❏ No

Handle laboratory samples ❏ Yes ❏ No

Control bleeding ❏ Yes ❏ No

Come in contact with a contaminated surface ❏ Yes ❏ No

Assist with childbirth or perform abortion ❏ Yes ❏ No

Provide intensive care (intubation, nasogastric tube insertion) ❏ Yes ❏ No

Perform minor surgery ❏ Yes ❏ No

Perform major surgery ❏ Yes ❏ No

Move a dead body ❏ Yes ❏ No

Perform an autopsy ❏ Yes ❏ No

Clean or disinfect a toilet ❏ Yes ❏ No

Handle sheets, clothes and mattresses ❏ Yes ❏ No

Provide care to family members ❏ Yes ❏ No

Other (specify): ____________________________________________________________________

Contact with EVD Patient(s)

10. Were you in contact** with someone who had suspected or confirmed EVD within 21 days before you became ill, without adequate personal protective equipment (PPE)***? ❏ Yes ❏ No

If no, skip to Question 18.

** Contact defined as a person who touches, without adequate PPE, a patient with symptoms of EVD

*** Adequate personal protective equipment = gloves, impermeable apron or full outfit with neck protection; rubber boots; and mask with protective visor or goggles

11. Has the person had a positive laboratory result for Ebola? ❏ Yes ❏ No

If no, skip to Question 16.

12. Does the person have an epidemiological link to a confirmed or probable case?

If no, skip to Question 16. ❏ Yes ❏ No

Local identification number _________________

13. Did the person only have a fever? ❏ Yes ❏ No

If no, skip to Question 16.

14. Did the person have fever and 3 or more of the following symptoms? ❏ Yes ❏ No

headache, vomiting / nausea, anorexia / loss of appetite, diarrhea, severe fatigue, abdominal pain, muscle or joint pain; difficulty swallowing, difficulty breathing, hiccups

15. Did the person have any sort of unexplained bleeding? ❏ Yes ❏ No

16. Where did the contact occur?

❏ Public hospital ❏ Transit Center

❏ Private hospital ❏ Community Treatment Center

❏ Laboratory ❏ Community Transit Center

❏ Clinic / Private practice ❏ Home

❏ Health center ❏ None

❏ Health post ❏ Other (specify): _____________________________

❏ Ebola Treatment Unit (ETU)

17. What was your relationship with this person (choose only one answer)

❏ Patient ❏ Friend

❏ Other health worker ❏ No relation

❏ Family or household member

❏ Other (specify): _____________________________

If you answered <other health worker> to the previous question, where did the contact take place?

❏ at work, in a care place intended for patients

❏ at work, in a place other than care unit (rest room, office, etc.)

❏ outside the workplace

18. Did you attend the funeral of someone who had Ebola in the 21 days before you became ill?

If no, skip to Question 20. ❏ Yes ❏ No

19. Were you involved in the preparation of the funeral by touching the body without adequate*** PPE?

❏ Yes ❏ No

*** adequate personal protective equipment = gloves, impermeable apron or full outfit with neck protection; rubber boots; and mask with protective visor or goggles

Most likely source of exposure to Ebola

20. Was there a single situation† that most likely led to your infection by Ebola?

If no, skip to Question 20. ❏ Yes ❏ No

†A most likely specific situation is one that occurred within 2 to 21 days before the onset of symptoms and involves a risk exposure with an infected person or their body fluids, or a corpse.

Specify the date (dd/mm/yy): __ __ / __ __ / __ __

Local identification number _________________

21. What was the place of suspected exposure?

❏ Public hospital ❏ Transit Center

❏ Private hospital ❏ Community Treatment Center

❏ Laboratory ❏ Community Transit Center

❏ Clinic / Private practice ❏ Home

❏ Health center ❏ In the community

❏ Health post ❏ None

❏ Ebola Treatment Unit (ETU) ❏ Other (specify): _____________________________

22. What was the mode of exposure?

❏ Splash of body fluid on intact skin ❏ Scalpel blade

❏ Splash of body fluid on non-intact skin ❏Unknown

❏ Splash of body fluid to the eye ❏ Other (specify):

❏Splash of body fluid on lips or mouth ____________________________________________

❏ Needle

23. What was the source of contamination?

❏ Blood ❏ Urine ❏ Pericardial fluid

❏ Body fluid contaminated with blood (visible) ❏ Cerebrospinal fluid ❏ Peritoneal fluid

❏ Vomit ❏ Synovial fluid ❏ Vaginal secretions

❏ Stool ❏ Pleural fluid ❏ Other (specify):

❏ Saliva ❏ Amniotic fluid _______________

Risk of infection prevention and control over the main place of work

24. Now, I will ask you how many times you have used specific components of personal protective equipment in the 21 days before you became ill. Tell me <never>, <sometimes> or <always> for each element.

Single pair of gloves (even if re-used) ❏ Always ❏ Sometimes ❏ Never

Double pair of gloves ❏ Always ❏ Sometimes ❏ Never

Heavy or cleaning gloves ❏ Always ❏ Sometimes ❏ Never

Disposable / waterproof apron ❏ Always ❏ Sometimes ❏ Never

Protective eyewear ❏ Always ❏ Sometimes ❏ Never

Face shield / visor ❏ Always ❏ Sometimes ❏ Never

Surgical mask ❏ Always ❏ Sometimes ❏ Never

Respirator (N95 or FFP2) ❏ Always ❏ Sometimes ❏ Never

Blouse - Long ❏ Always ❏ Sometimes ❏ Never

Blouse - Short ❏ Always ❏ Sometimes ❏ Never

Cap or hood ❏ Always ❏ Sometimes ❏ Never

Leg covers ❏ Always ❏ Sometimes ❏ Never

Shoe covers ❏ Always ❏ Sometimes ❏ Never

Closed resistant shoes ❏ Always ❏ Sometimes ❏ Never

Rubber boots ❏ Always ❏ Sometimes ❏ Never

Other (specify): _______________________________________________________________

Local identification number _________________

25. What hand hygiene products were available in the 21 days before you became ill? (check all that apply):

❏ Running (tap) water ❏ Soap ❏ Alcohol antiseptic

❏ Chlorinated water from tank ❏ Disposable towels

26. Now, I will ask you questions about hand washing related to specific situations. Do you wash your hands:

Before putting on gloves and PPE ❏ Yes ❏ No

Before a procedure ❏ Yes ❏ No

After an actual exposure or exposure to the risk of body fluid of a patient ❏ Yes ❏ No

After touching (even potentially) surfaces / items / equipments ❏ Yes ❏ No

After removing PPE ❏ Yes ❏ No

When leaving the treatment unit ❏ Yes ❏ No

27. During the 21 days before you became ill, were safety boxes available? ❏ Yes ❏ No

28. Have you been trained on the prevention and control of infections specifically for health personnel in the context of an Ebola epidemic? ❏ Yes ❏ No

Which organization conducted this training?

❏ Government ❏MSF ❏ Unknown

❏ WHO ❏ Red Cross

❏ CDC ❏ JHPIEGO

❏ Other (specify): ____________________________________________________________

Which organization conducted this training?

❏ Phase 1 (theoretical)

❏ Phase 2 (training session in the Health Center)

❏ Phase 3 (immersion in an Ebola Treatment Center)

What was the duration of training? ❏ < 1 day ❏ 1 day ❏ > 1 day

29. Additional details about the exposure and other comments:

_______________________________________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

Thank you for your time!