Questionnaire for Staff at the Clinic at the time of the

Form Approved

OMB No. 0920-XXXX

Exp. Date XX/XX/2016

Questionnaire for staff at the clinic at the time of event

What do you remember about the day of the event?

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Where were you when the event occurred?

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Did you provide care to the patient? If yes, what can you say about the patient’s routine?

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Who was the first person who found out about the event? What prompted that person to the finding and what was done first?

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Do you remember anything unusual about patient x on the day of the event?

-unusual vital signs?

-unusual labs?

-unusual behavior?

-unusual symptoms?

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Did you participate in the resuscitation?

If yes, could you describe what were done?

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If no, describe what you saw when they had the event?

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Were there any recent changes in protocols or procedures prior to the events?

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Were there any recent changes in medications or medication manufacturers or other supplies?

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Were there any recent changes in equipment?

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Were there any recent changes in staff (any staff, including service, house keeping…)?

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How long have you worked in dialysis clinics?

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How long have you worked here?

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What is your job here and what tasks do you do?

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What kind of training do you receive?

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Do you receive specific training on cardiac arrests? BLS? ACLS?

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Is there a defibrillator here? Do you know how to use it?

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What is the protocol when such an event occurs?

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How many events similar to this are you aware of?

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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)