GAS_IL Employee Questionnaire

Form Approved

OMB No. 0920-1011

Exp. Date 03/31/2017

Invasive GAS in LTCF 2015

Employee Survey

Date Completed: ____/____/____ □ Check box if documented case

A. Employee Background

1. Study Number: ___ ___ ___

2. Age:

3. Sex:  Male  Female

4. City of Residence:

6. List occupation:  RN/LPN  CNA  PT/OT  RNA

 Housekeeping  Dietary  Physician

 Pharmacist  Other __________________________

5. State of Residence:

B. Job Description

7. As part of your job, do you have physical contact with patients?  Yes  No

8. Areas usually worked:  Patient rooms  Nurses’ station  Cafeteria  Other _____________________

9. Shifts usually worked:  Day  Evening  Night  Other________________________

10. Patient units usually worked:  3W  2W  3E  2E  Do not work in patient units  All patient units

11. Which days do you usually work (circle ALL that apply):

Sunday

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

12. What kind of patient contact do you have? (check ALL that apply)

 Give oral medications  Feeding resident  Respiratory therapy  Tracheostomy care

 Change dressings/wound care  Gastrostomy care  Handle urinary catheter  Bathe resident

 Assist with patient transfer  Clean room  Handle soiled linens/bedding  Handle soiled diapers/bedpans

 Deliver meal trays  Take vital signs

C. Work Practice	13. Do you use soap and water to clean your hands?  Yes  No 14. Do you use alcohol-based gel to clean your hands?  Yes  No
15. Please answer the following questions (circle answer) Never Always a. Do you wash your hands BEFORE physical contact with patients? 1 2 3 4 5 N/A b. Do you wash your hands AFTER physical contact with patients? 1 2 3 4 5 N/A c. Do you wash your hands BETWEEN contact with patients? 1 2 3 4 5 N/A d. Do you use the sink in the patient’s bathroom? 1 2 3 4 5 N/A e. Do you use the sink at the nurse’s station? 1 2 3 4 5 N/A f. Do you use gloves when changing bandages/dressing wounds? 1 2 3 4 5 N/A If yes, do you change gloves between patients/patient rooms? 1 2 3 4 5 N/A g. Do you use gloves when cleaning soiled patients or linens? 1 2 3 4 5 N/A If yes, do you change gloves between patients/patient rooms? 1 2 3 4 5 N/A h. Do you use gloves when bathing patients? 1 2 3 4 5 N/A
D. Your Health	16. Do you have paid “Sick Leave”?  Yes  No 17. Did you receive prophylaxis for Group A Streptococcus infection?  Yes  No If yes, when? ______ / _______ / _______
18 a. Since May 2, 2015, did you have a sore throat?  Yes  No (If no, skip to #19) b. When? ______ / _______ / _______ c. Were you diagnosed with strep throat?  Yes  No d. Did you miss work for this illness?  Yes  No How many days did you miss? ____________ e. How many days were you ill? _____________ f. Did you receive antibiotics for this condition?  Yes  No If yes, antibiotic name ___________________
19 a. Since May 2, 2015, did you have a rash, open wound, or skin infection?  Yes  No (If no, skip to #20) b. When? ______ / _______ / _______ c. Did you miss work for this illness?  Yes  No How many days did you miss? ____________ d. How many days were you ill? _____________ e. Did you receive antibiotics for this condition?  Yes  No If yes, antibiotic name ___________________ f. What was your diagnosis? ____________________________
20 a. Since May 2, 2015, did you have fever, cough, and/or other respiratory infection?  Yes  No (If no, skip to #21) b. When? ______ / _______ / _______ c. Did you miss work for this illness?  Yes  No How many days did you miss? ____________ d. How many days were you ill? _____________ e. Did you receive antibiotics for this condition?  Yes  No If yes, antibiotic name ___________________ f. What was your diagnosis? ____________________________
21 a. How many people are in your household? __________ (If none, END) b. How many children under 18 years of age are in your household? _________ c. During the past 3 months, did anyone in your household have a sore throat?  Yes  No d. When? ______ / _______ / _______ e. Was he/she diagnosed with strep throat?  Yes  No f. Who? ____________ When? ______ / _______ / _______ g. Were they treated?  Yes  No If so, with what? ________________________________ h. During the past 3 months, did anyone in your household have impetigo or cellulitis (skin infections)?  Yes  No i. When? ______ / _______ / _______
22 a. Do you work in another patient-care facility?  Yes  No (If no, skip to End) b. Name of facility: ______________________________________________ c. Have you been in contact with a patient infected with group A Strep in that facility?  Yes  No (If no, skip to End) d. When? ______ / _______ / _______ e. What was that patient’s diagnosis?  Strep throat  Impetigo  Cellulitis  Bacteremia  Other __________________________________

END – Thank you!

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/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74 Atlanta, Georgia 30333; ATTN: PRA (0920-1011)

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