Questionnaire for Other Patients who were receiving Dial

Form Approved

OMB No. 0920-XXXX

Exp. Date XX/XX/2016

Questionnaire for other patients who were receiving dialysis at the same time of the event

Patient chair #:____ Shift:____ on regular dialysis schedule

Patient chair #:____ Shift:____ on the event date (if different)

What do you remember occurred during the event?

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Did you notice anything unusual about patient X during several days before the event?

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Did you notice anything unusual about patient X on that day before the event?

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Did you notice any recent changes at the facility?

Ask the following:

-New medications?

-New equipment?

-New ways of doing things before or during dialysis?

-New staff (any staff, including service and house keeping)

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What did they do when the event happened?

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Did you have any symptoms on that day during dialysis, such as shortness of breath, faint, anxious, itching, rash…)? Yes/No

If Yes, what were they and when did they occur?

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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