Inventory of ICs Y2Q2

Community Questionnaire: Knowledge, Attitudes, and Practices
Version 6: 4 July 2015

Form Approved
OMB No. 0920-1011
Exp. Date 03/31/2017

Unique ID (6 digits)__________________
Date of Interview__________ Interviewer Name_____________ CHV Name _____________
County_____________Sub-county________________Village/Town_____________Urban/Rural
GPS Coordinates of Household: Longitude____________________ Latitude____________________
Hello, my name is _______________. I am working with the Kenyan Ministry of Health and the
Centers for Disease Control and Prevention in Kenya and the US to investigate illnesses in the
community. We have a few questions about illness in the community and water issues. This may take
about 30-40 minutes. May I please speak to the person in the home who usually takes care of the ill
family members and brings the water for the family?
[READ ENROLLMENT SCRIPT TO GAIN CONSENT FOR PARTICIPATION. RECORD NO FOR REFUSALS.]
1. Consent to participate?
1 Yes
2. What is your age in years? _________ years

0 No, refusal
END SURVEY
3. Gender
1 Male
0 Female

Background Socioeconomic & Education
4. How many people live in your household?

#

5. How many children less than 5 years old live in your household?

#

Cholera General Knowledge Information
6. Have you ever heard of an illness called cholera?

7. Have you heard about the cholera outbreak in your area
recently?
8. Can you tell me what the main symptoms of cholera are?
(Do not read. Check all that are mentioned.)

9. What causes cholera?
(Do not read. Check all that are mentioned.)

1
0
99
1
0
99
1
2
3
4
5
6
99
1
2
3
4
5
6
7
8
99

Yes
No
Don’t Know
Yes
No
Don’t Know
Diarrhea
Vomiting
Fever
Dehydration
Decreased appetite
Other(specify)____________________
Don’t Know
Drinking bad water
Eating bad food
Unwashed fruit/vegetables
Flies/Insects
Poor hygiene
Open defecation
Spirits/Curse/Bad Omen
Other (specify) ____________________
Don’t Know

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 (0920-1011)

1

Community Questionnaire: Knowledge, Attitudes, and Practices
Version 6: 4 July 2015

10. Can cholera spread from one person to another?

11. How can you prevent you or your family members from
getting cholera?
(Do not read. Check all that are mentioned. Prompt after each
response.)

12. Where would you go for care if you or your family
member had cholera?
(Do not read. Check all that are mentioned. Prompt after each
response)

13. How would you treat cholera for yourself or your family
members when you are at home and cannot get to a
health facility?
(Do not read. Check all that are mentioned. Prompt after each
response)

Form Approved
OMB No. 0920-1011
Exp. Date 03/31/2017

1
0
99
0
1
2
3
4
5
6
7
8
9
10
99
1
2
3
4
5
6
7
8
9
10
11
12
99
1
2
3
4
5
6
7
8
9
10
11
12
13
99

Yes
No
Don’t know
Cannot prevent
Herbs
Wash hands
Cook food thoroughly
Reheat stored food
Cover food
Boil or treat water
Wash vegetables and fruit
Clean cooking utensils/vessels
Use a latrine/Avoid open defecation
Other (specify)____________________
Don’t Know
Private hospital
Government Hospital
Private health center/clinic
Government Health center/clinic
Dispensary
Cholera treatment center
Chemist
Kiosk/shop
Community health worker or volunteer
Traditional healer
Family or neighbor
Other (specify)_____________________
Don’t know
Increase liquid intake
Decrease liquid intake
Increase food intake
Decrease food intake
Use oral rehydration solution (ORS)
Use sugar-salt solution
Pill or syrup medicine
Injection
Go to church/ mosque/religious place
Go to traditional healer
Home remedy (specify)______________
Other (specify)_____________________
Do not treat
Don’t Know

2

Community Questionnaire: Knowledge, Attitudes, and Practices
Version 6: 4 July 2015

Cholera in Your Village/Neighborhood
14. Please tell me all the ways you heard about the cholera
outbreak.
(Do not read. Check all that are mentioned. Prompt after each
response.)

15. Did you hear messages about how to prevent cholera
from these sources of information (below)?

Form Approved
OMB No. 0920-1011
Exp. Date 03/31/2017

1
2
3
4
5
6
7
8
9
10

11
12
13
14
15
99
1
0
99

Family member
Neighbor
Friend
Chief (Baraza) Community Meeting
Community health worker/ volunteer
Health Worker
Women’s group
Church, Mosque or religious group
School
NGO or Volunteer Organization (ex. Red
Cross, MSF, UNICEF, ACF)
Radio
Electronic media (TV, internet, facebook)
Newspaper
Poster or Wall Hanging
Other (specify)__________
Don’t know
Yes
Go to 16
No
Go to 17
Don’t know
Go to 17

Family member, Neighbor, Friend
Chief (Baraza) Community Meeting
Community health worker/ volunteer
Health Worker
Women’s group
Church, Mosque or religious group
School
NGO or Volunteer Organization
Radio, Electronic media (TV, internet, facebook), Newspaper
Poster or Wall Hanging

16. What did you hear?

(Do not read. Check all that are mentioned. Prompt after
response.)

1
2
3
4
5
6
7
8

9

Boil or treat water
Build/Use latrines/Avoid open defecation
Wash hands
Cover food
Cook food thoroughly
Wash vegetables and fruit
Clean cooking utensils/vessels
Seek treatment if you have severe,
watery or bloody diarrhea
Other________________________

3

Community Questionnaire: Knowledge, Attitudes, and Practices
Version 6: 4 July 2015

Cholera in Household
17. Did you or someone in your household become ill with
cholera in the past 6 months?
Household=persons who eat from same pot or live under the
same roof
18. Have there been any deaths in your household due to
cholera in the past 6 months?

Form Approved
OMB No. 0920-1011
Exp. Date 03/31/2017

1
0
99

Yes
Go to 18
No
Go to 27
Don’t know
Go to 27

1
0

Yes
No

19. Did you use any of the following to treat yourself or others in your household when having diarrhea?
(Ask each item. Choose Yes, No or Don’t know for each item)
a. Herbal Treatment
Yes (1)
No (0)
Don’t Know (99)
b. Fluid prepared from ORS packet
Yes (1)
No (0)
Don’t Know (99)
c. Other solution prepared at home
Yes (1)
No (0)
Don’t Know (99)
d. Oral medicine/Antibiotics
Yes (1)
No (0)
Don’t Know (99)
e. Other (specify)______________________
Yes (1)
No (0)
Don’t Know (99)
20. Did you or someone in your household go for care for
cholera?
21. The last time (most recent time) you or someone in
your household went for care for cholera, who was
sick?

1
0
9
1
2

Yes
Go to 21
No
Go to 27
Don’t know
Go to 27
Respondent
Respondent’s family member
Other (specify)_______________

3

(The following questions 22-26 are about the person identified in question 21)
22. Did [you/ name of person in your household who had cholera] go for care at:
a. Private hospital
Yes (1)
No (0)
b. Government hospital
Yes (1)
No (0)
c. Private health center/clinic
Yes (1)
No (0)
d. Government health center /clinic
Yes (1)
No (0)
e. Dispensary
Yes (1)
No (0)
f. Cholera treatment center
Yes (1)
No (0)
g. Chemist
Yes (1)
No (0)
h. Kiosk/Shop
Yes (1)
No (0)
i. Community Health Worker or Volunteer
Yes (1)
No (0)
j. Traditional Healer
Yes (1)
No (0)
k. Family or neighbor
Yes (1)
No (0)
l. Other (specify)___________________________
Yes (1)
No (0)

Don’t Know (99)
Don’t Know (99)
Don’t Know (99)
Don’t Know (99)
Don’t Know (99)
Don’t Know (99)
Don’t Know (99)
Don’t Know (99)
Don’t Know (99)
Don’t Know (99)
Don’t Know (99)
Don’t Know (99)

If YES to ANY Health Facility (29 a,b,c,d,e,f)
Go to 30
If NO or Don’t know to ALL Health Facilities (29 a,b,c,d,e,f)
Go to 37

4

Community Questionnaire: Knowledge, Attitudes, and Practices
Version 6: 4 July 2015

23. What did they give [you/ name of person in your household
who had cholera] at the health facility to treat your cholera
illness? (Read all choices and check all that apply.)

24. Did the hospital take a stool test?

25. Did anyone at the health facility talk to you about
preventing cholera?

26. What did they talk about? (Do not read. Check all
mentioned. Prompt after response).

Form Approved
OMB No. 0920-1011
Exp. Date 03/31/2017

1
2
3
4
5
6
7
8
9
99
1
0
99
1
0
99

ORS
Fluid through a needle / IV Fluids
Syrup or pill medicine by mouth
Injection
Antibiotics
Anti-motility medicine
Zinc sulfate
Special air through a mask / Oxygen
Other (specify)_________________
Don’t Know
Yes
No
Don’t know
Yes
Go to 26
No
Go to 27
Don’t know
Go to 27

1
2
3
4
5
6
7
8
9

Treat water
Build and use latrines
Wash hands
Cover food
Cook food thoroughly
Reheat stored food
Wash vegetables and fruit
Clean cooking utensils/ vessels
Seek treatment if severe, watery,
bloody diarrhea
Diarrhea and children
Other (specify) _______________
Don’t know

10
11
99

Health-seeking Behavior
Now, I would like to ask you some questions about the health facility where you mainly go for
care.
27. How many hours does it take to get to the health facility
from your home?

Oral Rehydration Solution (ORS)
28. Have you heard of Oral Rehydration Solution or ORS?

1
2
3
4
5
99

1
0
99

0-30 minutes
30-60 minutes
1-3 hours
3-6 hours
>6 hours
Don’t know

Yes
Go to 29
No
Go to 32
Don’t know
Go to 32

5

Community Questionnaire: Knowledge, Attitudes, and Practices
Version 6: 4 July 2015

29. What is ORS used to treat?
(Do not read. Check all that are mentioned.)

30. Where is ORS available ?
(Do not read. Check all that are mentioned.)

31. Have you received ORS for free in the past 6 months?

Water and Water Treatment Information
32. What is the main source of your household’s drinking water
during the DRY season? (Do not read; Choose 1)

33. What is your main source of drinking water during the RAINY
season? (Do not read; Choose 1)

Form Approved
OMB No. 0920-1011
Exp. Date 03/31/2017

1
2
3
4
99
1
2
3
4
5
6
7
99
1
0
99

Dehydration
Diarrhea
Children’s illnesses
Other (specify)___________________
Don’t Know
Health care facility
Chemist/Pharmacy
Kiosk/Shop in Village
Supermarket
NGO
Other (specify)__________________
Not available
Don’t know
Yes
No
Don’t know

1
2
3
4
5
6
7
8
9
10
11
12
13
14
1
2
3
4
5
6
7
8
9
10
11
12
13
14

Open deep well
Protected deep well
Shallow well/hand-dug well
Spring
Lake
Pond/Seasonal lake
River
Borehole
Rain water catchment from roof
Piped water to house
Community tap
Water vendor
Dam
Other (specify)________________
Open deep well
Protected deep well
Shallow well/hand-dug well
Spring
Lake
Pond/Seasonal lake
River
Borehole
Rain water catchment from roof
Piped water to house
Community tap
Water vendor
Dam
Other (specify)________________

6

Community Questionnaire: Knowledge, Attitudes, and Practices
Version 6: 4 July 2015

34. Where are you presently getting your water?
(Do not read; Choose 1)

35. Are there any times during the year when water is not
readily/easily available?

36. During the past 6 months, how often was water not
readily/easily available? (Read choices. Choose only 1.)

37. Why was water not readily available?

38. Do you do something to your drinking water to make it safe
to drink?
39. What do you do to treat the water?

(Do not read. Check all that are mentioned. Prompt after each
response.)

Form Approved
OMB No. 0920-1011
Exp. Date 03/31/2017

1
2
3
4
5
6
7
8
9
10
11
12
13
14
1
0

Open deep well
Protected deep well
Shallow well/hand-dug well
Spring
Lake
Pond/Seasonal lake
River
Borehole
Rain water catchment from roof
Piped water to house
Community tap
Water vendor
Dam
Other (specify)________________
Yes
Go to 36
No
Go to 38

1
2
3
4
5
99
1
2
3
4
99
1
0
99
1
2
3
4
5
6
7
8
9
10
11
12
13
99

One week during past 6 months
One month during past 6 months
1- 3 months during past 6 months
Over 3 months during past 6 months
Other (specify)_______________
Don’t know
Drought
Water rationing
Broken pipes/ water system
Other (specify)_________________
Don’t know
Yes
Go to 39
No
Go to 40
Don’t know
Go to 40
Boil
Decanting
Keep water in hot sun
Filter
Cloth filter
Sand (shallow dug well)
Alum
WaterGuard
PuR
AquaGuard
Aquatabs
Use a ceramic/biosand filter
Other (Specify)_________________
Don’t know

7

Community Questionnaire: Knowledge, Attitudes, and Practices
Version 6: 4 July 2015

40. In the last 6 months, have you ever received any water
treatment products or hygiene products or kits for free from
the government, NGO, or another organization (to prevent or
treat cholera)?

41. What were you given?
(Do not read. Check all that are mentioned.)

42. Were you given any counseling or education on how to use
these water treatment products?
43. Did you use any of these products?

44. Why did you not use these products?

Form Approved
OMB No. 0920-1011
Exp. Date 03/31/2017

1
0
99

Yes
Go to 41
No
Go to 45
Don’t know
Go to 45

1
2
3
4
5
6
7
8
8
9
10
11
12
13
14
15
16
1
0
99
1
0
99
1
2
3
4
5
6
7
99

WaterGuard
Go to 42
PuR
Go to 42
AquaGuard
Go to 42
Aquatabs/chlorine tabs
Go to 42
Bottles of chlorine
Go to 42
Drums of chlorine
Go to 42
Hygiene kit
Go to 42
Soap
Jerrycan
Bucket
Ceramic water filter
Medicine/Antibiotics
Go to 45
ORS
Print material
Incentives
Advice
Other____________________
Yes
No
Don’t know
Yes
Go to 45
No
Go to 44
Don’t know
Go to 45
Bad Taste
Dangerous to use these products
No container to treat water
No need to treat water
Did not know how to use the product
Did not know where to get product
Other (specify)_________________
Don’t know

8

Community Questionnaire: Knowledge, Attitudes, and Practices
Version 6: 4 July 2015

Handwashing Information
45. When do you wash your hands?
(Do not read. Check all that are mentioned.)

46. Do you have soap in the house?
(If possible, observe soap if say yes.)

Form Approved
OMB No. 0920-1011
Exp. Date 03/31/2017

1
2
3
4
5
6
7
8
99
1
0
99

After using the toilet
Before eating
After eating
When serving meals
Before cooking
After cleaning babies when they defecate
Other (Specify) ___________________
Never wash hands
Don’t Know
Yes
Observed? Yes (1) , No (0)
No
Don’t know

Devolution
Now, we would like to ask you some questions about how devolution may have changed health
services in your community.
47. Since devolution, which changes (if any) have you
0
None / no changes in health services
noticed in health services in your community?
1
Better services
(Do not read. Check all that are mentioned. Probe.)
2
Worse services
3
Shorter wait times
4
Longer wait times
5
Less fees for health services
6
More fees for health services
7
Other (Specify)_____________________
99 Don’t know
Education/Socioeconomic/Personal Information
A number of cholera messages have been sent by the Ministry of Health and partners about this
outbreak and we want to know how they reached you. We also ask a few questions about household
income and religion so we can know all who are represented in this survey.
48. Can you read and write?
1
Yes
0
No
99 Don’t know
49. What is the highest level of education you have
0
None
attended? (Choose only 1)
1
Lower Primary
2
Upper Primary
3
Secondary or Higher
4
Other (specify)______
99 Don’t know

9

Community Questionnaire: Knowledge, Attitudes, and Practices
Version 6: 4 July 2015

50. Does your household have the following?
(Read all choices. Mark all that apply.)

51. What is the main source of family income?
(Do not read. Choose only 1.)

52. What is your religious denomination?
(Do not read. Check all that are mentioned.)

Home Information/Observations
Now I will ask you some questions about your home.
53. May I see where you store your water?
(Mark all that are seen.)

54. Where do you defecate? May I see where?
(Mark what is seen if possible. Do not read. Circle the one
that applies.)

Form Approved
OMB No. 0920-1011
Exp. Date 03/31/2017

1
2
3
4
5
6
7
8
9
10
0
1
2
3
4
5
6
99
1
2
3
4
5
99

Electricity
Television
Radio
Animal-drawn cart
Motorcycle/Scooter
Bicycle
Car/truck
Refrigerator
Telephone (mobile or non-mobile)
Agricultural land
None of the above
Small Business/Trader
Fishing
Farmer
Employed/Salaried
Unskilled labor
Unemployed
Don’t Know
Christian
Muslim
Hindu
None
Other (specify)_________________
Refused

0
1
2
3
4
5
99
1
2
3
4
5
6
7
8

None
Jerrycan
Bucket
Pot
Cooking pot (Sufuria)
Water Tank
Refused
Flush Latrine
Covered pit latrine
Uncovered dry pit latrine
Flying toilet
Bush
Lake or River
Other, (Specify) _____________________
Paid toilet

10

Community Questionnaire: Knowledge, Attitudes, and Practices
Version 6: 4 July 2015

55. May I see the products you have purchased or
have received from the government or NGOs?

(Mark all that are seen.)

56. Have you treated the drinking water you are using
today with these products?
57. May I test a sample of drinking water to see if
there is chlorine in it?

Form Approved
OMB No. 0920-1011
Exp. Date 03/31/2017

1
2
3
4
5
6
7
8
9
10
11
12
0
1
0
1
2
3
4

Soap
WaterGuard
PuR
Aquatabs/chlorine tabs
Bottles of chlorine
Drums of chlorine
Ceramic water filter
Medicine/Antibiotics
ORS
Food
Print material
Other (specify)_______________________
None in the home
Yes
No
Chlorine test performed
Go to 58
No water stored
END SURVEY
Test not done
END SURVEY
Other (specify)__ ________
END SURVEY
Refused
END SURVEY

99
58. HOUSEHOLD DRINKNG WATER: Free chlorine
residuals

Test turned pink: Yes (1), No (0)

_._ _ mg/L (#, 2 decimal places)
59. SOURCE DRINKNG WATER: Free chlorine residuals

Test turned pink: Yes (1), No (0), Not tested (9)

_._ _ mg/L (#, 2 decimal places)

“The interview is now finished. Thank you for your time”
NOTE: Give soap as a token of thanks for the participant AFTER the interview.

11

Interviewer____________________
Health Facility ID_________________
Unique ID _________________

Version 2: 5 July 2015

Form Approved
OMB No. 0920-1011
Exp. Date 03/31/2017

Health Care Worker Survey
Elicit answers from all nurses, clinical officers, and medical officers working in the inpatient and
outpatient section of the health center, dispensary, or hospital.
NOTE: If more than one staff in the clinic/hospital, interview the NURSE IN CHARGE first and then
the rest of the medical staff who are available.
The Kenyan Ministry of Health in collaboration with the Centers for Centers for Disease Control and
Prevention (CDC) in Kenya and the US is conducting a cholera assessment because of the ongoing outbreak
across the country. We would like to ask you some questions about the types of cholera patients you have
been attending to. We are wondering if you would be willing to answer some questions. This survey should
take approximately 30 minutes to complete.
Are you willing to participate in this survey?
Yes
continue to Section A

No
If NO, thank them for their time.

County:_______________________

Sub-county:________________________

A.
1.
2.
3.
4.

IDENTIFYING INFORMATION
Date of interview
Age of Respondent
GPS coordinates
Sex of Respondent

5. Location Employed

6. What type of medical facility is this facility?
(read all options, select one)

7. Does this health facility admit patients
overnight?
8. What days areyour facility open?

1

_____________________
__________ years
______________________
1 Male
2 Female
1 National Referral Hospital
2 County Hospital
3 Sub-county Hospital
4 Community Health Centre
5 Dispensary (name:______________________)
6 Other: (specify)_________________________
7 Private facility
8 Faith-based facility
1 Government (MOH)
2 Private
3 Faith-based
4 NGO
5 Other (specify)___________________________
1 Yes
0 No
99 Don’t know
1 Every day
2 Monday – Friday
3 Monday – Saturday
4 Other (specify)___________________________
99 Don’t know

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)

Interviewer____________________
Health Facility ID_________________
Unique ID _________________
9. How many hours are your facility open?

10. Which one of the following healthcare worker
categories best describes your current position?
(read all options, select one)

11. Please indicate the training you have
completed for your chosen healthcare profession
(read all options, select one)

12. How many years have you been practicing in
your chosen health profession?
13. How many years have you been practicing in
this facility?

Version 2: 5 July 2015
OMB No. 0920-1011

1
2
3
4
99
1
2
3
4
5
6
7

24 hours a day
8-12 hours a day
Less than 8 hours a day
Other (specify)________________________
Don’t know
Medical officer
Clinical officer
Nurse
Nurse in charge
Community Health Worker/Patient attendant
Lab technician
Other (specify)_________________________

1
2
3
4
5

No formal training
Medical school
Clinical officer training
Nursing school
Other (specify)__________________________
___________ years
____________years

Now I will ask you about cholera patients you have seen.
B. CHOLERA PATIENTS IN THE HCF
1. Did you see any cholera (suspected or
1
Yes
Go to 1a
confirmed) patients at this facility in 2015?
0
No
Go to C1
99 Don’t know
1a. In the past week how many patients with
cholera (suspected or confirmed) have you
________patients
treated?
2. Within this facility, where are/where were
1
Regular ward/clinic
suspected or confirmed cholera cases treated?
2
Separate cholera ward (within hospital/center)
3
Cholera Treatment Centre (CTC), separate from
the hospital/health centre
4
Other (specify)____________________________
5
No cholera cases admitted
go to C1
99 Don’t know
3. Have you treated patients for cholera in this
1
Yes
facility as outpatients?
0
No
99 Don’t know
4. Have you admitted patients with cholera
1
Yes
overnight in this facility?
0
No
99 Don’t know

2

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)

Interviewer____________________
Health Facility ID_________________
Unique ID _________________

Version 2: 5 July 2015
OMB No. 0920-1011

5. Have any patients died of cholera in this health
facility in 2015?

1
0
99

Yes
Go to 5a
No
Go to C1
Don’t know

5a. In 2015, about how many patients have
died from cholera in this health facility?

1
2
3
4
99
1
2
3

0
1-5
6-10
>10
Don’t know
Late diagnosis or initial misdiagnosis
Late presentation to facility
Inadequate staff in the facility to manage severelyill patients
Lack of necessary supplies to treat the patient
Other (specify)___________________________
Don’t know

5b. Why do you think these patients died of
cholera?

4
5
99
Now I will ask you about the disease cholera.
C. KNOWLEDGE
1. Have you received any training on how to
manage cholera patients?
1a. If YES, what year was this training?
1b. If YES, from whom did you receive the
training?

2. What case definition do you use for cholera?
(do not read, circle all that are mentioned)

1
0
1
2
3
4
5
99
1
2
3

3. Name at least one way that cholera is
transmitted (don’t read, select all that apply)

4. Can cholera be prevented?

3

4
5
6
99
1
2
3
5
99
6
1
0
99

Yes
Go to 1a
No
Go to 2
__________(year only)
Ministry of Health
Private organization (specify)________________
During schooling
NGO (specify)____________________________
Other (specify)____________________________
Don’t know/remember
Severe dehydration from acute watery diarrhea (>4
episodes in 12 hours) in a patient of any age
Severe dehydration from acute watery diarrhea (>4
episodes in 12 hours) in a patient >5 years old
Acute watery diarrhea in a person >2 years old in
an area where there is an outbreak of cholera
Acute watery diarrhea in a person >2 years old
Any diarrhea
Other (specify)___________________________
Don’t Know
Contaminated Food
Contaminated Water
Other (specify)____________________________
Person-to-person
Don’t Know
Fecal-oral route
Yes
go to 4a
No
go to 5
Don’t Know
go to 5

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)

Interviewer____________________
Health Facility ID_________________
Unique ID _________________

4a. If YES, how can cholera be prevented?
(Don’t read, select all that apply)

5. What are signs of severe dehydration in a
patient?
(read all options, select all that apply)

6. When you see a cholera patient with severe
dehydration, what type of fluids would you give
them ideally? (read all options, select one)
6a. What type of intravenous fluids would you
give a patient with severe dehydration?
(read all options, select one)

7. If you see a cholera patient with some
dehydration and no vomiting, what type of fluids
would you give them ideally? (read answers,
select only one)
8. If you see a cholera patient with no signs of
dehydration, what do you do? (read answers,
select only one)

9. If you see a cholera patient who is vomiting,
when can you give them ORS?
(read answers, select only one)

4

Version 2: 5 July 2015
OMB No. 0920-1011

1
2
3
4
5
6
7
99
1
2
3
4
5
6
7
8
9
10
99
1
2
0
99
1
2
3
4
5
99
1
2
0
99
0
1
2
3
99
1
2
3
4
99

Wash hands
Cook food thoroughly
Cover food
Boil or treat water
Wash fruits and vegetables
Clean cooking utensils
Other (specify)____________________________
Don’t know
Lethargic or unconscious
Crying with visible tears
Weak distal pulses
Normal skin pinch
Very sunken eyes
No or decreased urine output
High blood pressure
Low blood pressure
High pulse rate
Other (specify)____________________________
Don’t know
Oral Rehydration Solution (ORS) only
go to 7
Intravenous fluid and ORS
go to 6a
None of the Above
go to 7
Don’t Know
go to 7
Ringer’s Lactate (LR)/ Hartmann’s solution
Plasma
0.9% Normal Saline (NS)
5% Dextrose (D5W)
Other (specify)____________________________
Don’t Know
Oral Rehydration Solution (ORS) only
Intravenous fluid and ORS
None of the Above
Don’t Know
Nothing, send them home
Give ORS to take home
Give intravenous fluids
Other (specify)___________________________
Don’t Know
Immediately
After IV fluids
When vomiting has stopped
Other (specify)____________________________
Don’t know

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)

Interviewer____________________
Health Facility ID_________________
Unique ID _________________
10. When is it appropriate to feed a cholera
patient? (read answers, select only one)

11. TRUE/FALSE: Infants and young children
with cholera should continue breast-feeding as
long as they are not vomiting
12. Which cholera patients should receive oral
antibiotics? (read answers, select only one)

13. Which antibiotics are given to adult cholera
patients in your facility? (read answers, select all
that apply)

Version 2: 5 July 2015
OMB No. 0920-1011

1
2
3
99
1
2
99
1
2
3
99
1
2
3
4
5
99

Never
As soon as they are able to eat without vomiting
Other (specify)____________________
Don’t know
True
False
Don’t know
All patients
Only patients with severe dehydration
Only pediatric patients
Don’t know
Doxycycline
Tetracycline
Chloramphenicol
Erythromycin
Other (specify)____________________
Don’t know

Now I will ask you about your attitudes toward cholera.
D. ATTITUDE
1. Are you worried about getting cholera from
your patients?
2. Do you believe that cholera is curable with
proper treatment?

1
0
1
0

Yes
No
Yes
No

E. PRACTICES
E1. Supplies
Now I will ask you some questions about the availability of supplies in your facility.
1. Do you have ORS in your facility?
1
Yes
0
No
99 Don’t know
1a. In 2015, did you ever run out of ORS?
1
Yes
Go to 1b
0
No
Go to 2
99 Don’t know
1b. Why did you run out of ORS?
1
In-between orders
2
Shortage of stock at distributor level
Go to 1c
3
Other (specify)_________________________
99 Don’t know
1c.What was the longest period of time you
1
<1 week
had a stock out of this product?
2
1 week – 1 month
3
1 – 3 months
4
3– 6 months
5
>6 months
6
Other (specify)_________________________
99 Don’t know

5

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)

Interviewer____________________
Health Facility ID_________________
Unique ID _________________
2. Do you have intravenous fluids (IVF) in
your facility?
2a. In 2015, did you ever run out of
intravenous fluids?
2b. Why did you run out of IVF?

2c. What was the longest period of time you
had a stock out of this product?

3. Do you have doxycycline in your facility?

3a. In 2015, did you ever run out of
doxycycline?
3b. Why did you run out of doxycycline?

3c. What was the longest period of time you
had a stock out of this product?

Version 2: 5 July 2015
OMB No. 0920-1011

1
0
99
1
0
99
1
2
3
99
1
2
3
4
5
6
99
1
0
99
1
0
99
1
2
3
99
1
2
3
4
5
6
99

Yes
No
Don’t know
Yes
Go to 2b
No
Go to 3
Don’t know
In-between orders
Shortage of stock at distributor level
Other (specify)__________________________
Don’t know
<1 week
1 week – 1 month
1 – 3 months
3 – 6 months
>6 months
Other (specify)__________________________
Don’t know
Yes
No
Don’t know
Yes
Go to 3b
No
Go to 4
Don’t Know
Go to 4
In-between orders
Shortage of stock at distributor level
Other (specify)_________________________
Don’t know
<1 week
1 week – 1 month
1 – 3 months
3 – 6 months
>6 months
Other (specify)__________________________
Don’t know

E2. Laboratory
Now I will ask some questions about cholera laboratory tests.
4. Are stool samples collected from suspected
1
Yes
go to 4a
cholera patients in your facility?
0
No
go to 5
99
Don’t know
go to 5
4a. Are stool samples cultured for cholera in
1
Yes
go to 4b
your facility?
0
No
go to 5
99
Don’t know
go to 5
4b. Where are stool samples sent for culture?
1
County hospital lab
2
National lab
3
Other (specify)_________________________
99 Don’t know

6

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)

Interviewer____________________
Health Facility ID_________________
Unique ID _________________

Version 2: 5 July 2015
OMB No. 0920-1011

4c. Are culture results sent back to your
facility?

1
Yes
0
No
99
Don’t Know
5. Do you have rapid cholera tests in your
1
Yes
go to 5a
facility?
0
No
go to 6
99
Don’t Know
go to 6
5a. Did you ever conduct a rapid cholera test
1
Yes
on any patients in 2015?
0
No
99
Don’t Know
E3. ORS. Now I will ask you some questions about ORS
6. Do you make ORS for cholera patients in this
1
Yes
go to 6a
facility?
0
No
go to 7
99 Don’t know
go to 7
6a. Is the facility water used to make ORS
1
Yes
go to 6b
treated?
0
No
go to 7
99 Don’t Know
go to 7
6b. How is water treated? (observe the water
0
No water treatment available
1
Boiling
treatment and circle all the water treatments
Jik
observed. If no water treatment available to view, 2
3
WaterGuard
mark No water treatment available)
4
AquaTabs
5
AquaGuard
6
Pur
7
Other (specify)_______________
99 Don’t know
6c. From whom did you receive the water
treatment products?

1
Government
2
NGO (specify)________________________
3
Other _______________________________
99 Don’t know
F. DEVOLUTION. Now I’m going to ask you some questions about devolution.
1. Since devolution, have you noticed any
1
Yes
changes in work conditions?
0
No
99 Don’t know
2. If yes, what changes have you noticed?
1
(Don’t read, select all that apply and prompt 2
3
for multiple responses)
4
5
6
7
8
9
10
11
99

7

No change
Better work environment
Worse work environment
Better salary
Worse salary
Not getting paid on time
More supplies/No or minimal stock outs
Less supplies/More stock outs
More staff
Less staff
Other (specify)________________________
Don’t know

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)

Interviewer____________________
Health Facility ID_________________
Unique ID _________________

3. Since devolution, have you noticed any
changes in quality of patient care?

Version 2: 5 July 2015
OMB No. 0920-1011

1
0
99

4. If yes, what changes have you seen?
1
(Don’t read, select all that apply and prompt 2
3
for multiple responses)
4
5
6
7
8
9
10
11
99

8

Yes
No
Don’t know
No change
Better patient care
Worse patient care
Higher fee for service
Lower fee for service
Paying for services that are supposed to be free
Shorter wait times
Longer wait times
Less patients come to your facility
More patients come to your facility
Other (specify)________________________
Don’t know

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)

Interviewer__________________
UNIQUE ID#___________________

July 5, 2015

Form Approved
OMB No. 0920-1011
Exp. Date 03/31/2017

Community Health Extension Worker Survey
The Kenyan Ministry of Health, in collaboration with the U.S. Centers for Centers for Disease Control and
Prevention (CDC), is conducting a study on cholera. We would like to ask you some questions about your
role in the cholera response and about cholera patients that you may have seen. We are wondering if you
would be willing to answer some questions. This survey should take approximately 30 minutes to complete.
County_________

Sub-county_________________

Village/Town_______________

UNIQUE ID: (6 digits, letter and numbers):___________________
Would you be willing to participate in this survey?
Yes
continue to Section A
A. IDENTIFYING INFORMATION
1. Date of interview
2. Age of Respondent
3. Sex of Respondent
4. Job Title

No
If NO, thank them for their time.

1
2
1
2
3

_____________________
__________ (years)
Male
Female
Community Health Extension Worker
Community Health Volunteer
Other (specify)______________________

1
2
3
4
5

_____________________________
No formal education
Religious education only
Primary school – did not complete
Completed primary school
Some secondary school or higher

5. Catchment area
6. Highest education level

7. How many households do you (and
community health volunteers) cover?
8. How often do you (or community health
volunteers) visit these households?

1
2
3
4
9. Who is your employer?
1
2
3
4
5
10. Who pays your salary/stipend?
1
2
3
4
5
11. Are there times that you have not been paid 1
in 2015?
0
12. How long have you been working in this
position?

_________________
Once per week
Once every 2 weeks
Once per month
Other (specify)_______________
Government (MOH)
Private
Faith-based
NGO
Other (specify)___________________
Government (MOH)
Private
Faith-based
NGO
Other (specify)___________________
Yes
No
___________months
___________ years

13. Do you supervise Community Health
Volunteers?

Yes
go to 13a
No
go to B1

1
0

Public reporting burden of this collection of information is estimated to average 20 minutes per response, including the time for reviewing instructions,
1
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)

Interviewer__________________
UNIQUE ID#___________________
13a. How many Community Health
Volunteers do you supervise?
13b. Are your Community Health
Volunteers paid?
13c. Are there times the Community Health
Volunteers are NOT paid?

July 5, 2015

________________________________________
1 Yes
go to 13c
0 No
go to B1
1 Yes
0 No
99 Don’t know

13d. What is the monthly stipend of your
Community Health Volunteers?

____________KSH/month

Now I will ask you about cholera patients you have seen.
B. CHOLERA PATIENTS
1. How many cholera (suspected or
1
Yes
go to 1a
confirmed) patients have there been in your
0
No
go to C1
area this year (2015)?
99 Don’t know
go to C1
1a. In the past week, how many patients
with cholera patients (suspected or
_______________
confirmed) have there been in your area?
2. Has anyone died in their home due to
1
Yes
go to 2a
cholera in your area this year (2015)?
0
No
go to 3
99 Don’t know
go to 3
2a. How many people died in their home
1
1-5
due to cholera in your area in the past 6
2
6-10
months? (best estimate)
3
>10
99 Don’t know
3. In your experience, do some people with
1
Yes
go to 3a
cholera in your area not go to a health care
0
No
go to C1
facility to seek medical care?
99 Don’t know
go to C1
3a. Why do some people who are sick
1
Lack of knowledge about cholera
with cholera not seek medical care?
2
Challenges with transportation
3
Lack of money to pay for medical services/transport
4
Traditional healers are preferred to health facilities
5
People prefer to treat themselves at a chemist/kiosk
6
Other____________________________________
99 Don’t know
Now I will ask you about the disease cholera.
C. KNOWLEDGE
1. Have you received any training oncholera
prevention and treatment?
1a. If YES, what year was this training?
1b. If YES, from whom did you receive the
training?
(Do not read. Check all that are mentioned.)

1
0

Yes
go to 1a
No
go to 2
__________(year only)

1
2
3
4
5
99

Ministry of Health
Private organization (specify)_______________
During schooling
NGO (specify)___________________________
Other (specify)___________________________
Don’t know

2

Interviewer__________________
UNIQUE ID#___________________
2. How is cholera transmitted?
(Do not read. Check all that are mentioned.)

3. Can you tell me what the main symptoms of
cholera are?
(Do not read. Check all that are mentioned.)

4. Can cholera be prevented?

4a. How can cholera be prevented?
(Do not read. Check all that are mentioned

5. If you see a patient you think has cholera,
what do you do?
(Do NOT read all. Check only one.)

July 5, 2015

1
2
3
4
99
5
1
2
3
4
5
6
99
1
0
99
1
2
3
4
5
6
7
99
1
2
3
99

Contaminated food
Contaminated water
Person-to-person
Other (specify)_____________________________
Don’t know
Fecal-oral route
Diarrhea
Vomiting
Fever
Dehydration
Decreased appetite
Other (specify)___________________________
Don’t Know
Yes
go to 4a
No
go to 5
Don’t Know
go to 5
Wash hands
Cook food thoroughly
Cover food
Boil or treat water
Wash fruits and vegetables
Clean cooking utensils
Other (specify)__________________________
Don’t know
Refer/Transport patient to a hospital or Cholera
Treatment Center
Give the patient ORS and send them home
Take the patient to a traditional healer
Don’t know

Now I will ask you about your attitudes regarding cholera.
D. ATTITUDE
1. Are you worried about getting cholera from 1
Yes
others in your community?
0
No
99 Don’t know
2. Do you believe that cholera is curable with 1
Yes
proper treatment?
0
No.
99 Don’t know
Now I will ask you about some of your practices during the current 2015 cholera outbreak
E. PRACTICES
1. During the current 2015 cholera outbreak, which of the following activities did/do you perform?
(Ask each item. Choose Yes or No for each item.)
A. Facilitated cholera related trainings for community
Yes (1)
No (0)
health volunteers (CHVs)
B. Provided supervision to CHVs on suspected cholera
Yes (1)
No (0)
cases or investigations
C. Referred suspected cholera cases to health care
Yes (1)
No (0)
facilities
D. Performed door-to-door case finding (active
Yes (1)
No (0)
surveillance)
E. Traced contacts of cholera cases
Yes (1)
No (0)
3

Interviewer__________________
UNIQUE ID#___________________

July 5, 2015

Yes (1)
go to ff

F. Distributed household water treatment supplies
ff. If yes, what water treatment supplies did you
distribute? (Don’t read, select all that apply)

1
2
3
4
5
6
99
1
0
1
2
3
4
5
6
7
8
9
10
11
12
13
99

G. Taught household water treatment
H. If yes, what methods did you teach? (Don’t read,
select all that apply)

No (0)
go to G

Alum
WaterGuard
PuR
AquaGuard
Aquatabs
Other (specify)______________
Don’t know
Yes
go to H
No
go to I
Boil
Decanting
Keep water in hot sun
Filter
Cloth filter
Sand (shallow dug well)
Alum
WaterGuard
PuR
AquaGuard
Aquatabs
Use a ceramic/biosand filter
Other (specify)______________
Don’t know

I. Distributed ORS (oral hydration solution)
Yes (1)
go to ii
No (0)
go to J
ii. If yes, did you teach how to mix the ORS?
Yes (1)
No (0)
J. Taught communities about other cholera prevention
Yes (1)
go to jj
No (0)
go to K
methods
jj. If yes, what things did you talk about? 1
Treat water
2
Build and use latrines
(Don’t read, select all that apply)
3
Wash hands
4
Cover food
5
Cook food thoroughly
6
Reheat stored food
7
Wash vegetables and fruit
8
Clean cooking utensils/ vessels
9
Seek treatment if severe watery diarrhea
10 Diarrhea and children
11 Other (specify)____________________________
99 Don’t know
K. Other (specify)_____________________________
Yes (1)
No (0)
Now I’m going to ask you some questions about devolution.
F. DEVOLUTION

1. Since devolution, have you noticed any
changes in your work conditions?

1
0
99

Yes
No
Don’t know
4

Interviewer__________________
UNIQUE ID#___________________

July 5, 2015

1
2. If yes, what changes have you noticed?
(Don’t read, select all that apply and prompt 2
3
for multiple responses)
4
5
6
7
8
9
10
11
99

No change
Better work environment
Worse work environment
Better salary
Worse salary
Not getting paid on time
More supplies/No or minimal stock outs
Less supplies/More stock outs
More staff
Less staff
Other (specify)_______________________
Don’t know

3. Since devolution, have you noticed any
changes in quality of patient care?

Yes
No
Don’t know

1
0
99

4. If yes, what changes have you seen?
1
(Don’t read, select all that apply and prompt 2
3
for multiple responses)
4
5
6
7
8
9
10
11
99

No change
Better patient care
Worse patient care
Higher fee for service
Lower fee for service
Paying for services that are supposed to be free
Shorter wait times
Longer wait times
Less patients come to your HCF
More patients come to your HCF
Other (specify)________________________
Don’t know

5

Version 3: 5 July 2015
Form Approved
OMB No. 0920-1011
Exp. Date 03/31/2017

Interviewer____________________
Health Facility ID_________________
HEALTHCARE FACILITY CHECKLIST

NOTE: Ask the CHIEF MEDICAL OFFICER or NURSE IN CHARGE to help you complete this checklist. Only fill one
checklist per healthcare facility. If the neither is available, ask the next highest ranking healthcare worker.

The Kenyan Ministry Health in collaboration with the US Centers for Centers for Disease Control and
Prevention (CDC) is conducting a study on cholera. We would like to ask you some questions about the
types of cholera patients you are seeing and how they are being treated. We are wondering if you
would be willing to answer some questions. This survey should take approximately 30 minutes to
complete.
No
If NO, thank them for their time

If Yes
continue to Section A
County__________________________

Sub-County________________________

PATIENT CARE
Item observed

In Stock? Y/N

Doxycycline

Yes___

No___

Erythromycin

Yes___

No___

Other Antibiotic for used cholera
____________________
ORS(oral rehydration solution)

Yes___

No___

Yes___

No___

Intravenous fluids (i.e Ringer’s Lactate)
IV tubing and needles (pediatric)

Yes___
Yes___

If in stock, most recent
expiration date?

If in stock, rough estimate
of stock

Exp:________________

Quantity________________

Exp:________________

Quantity________________

Exp:_________________

Quantity________________

Exp:_________________

Quantity________________

Exp:_________________

Quantity________________

Exp:_________________

Quantity________________

Exp:_________________

Quantity________________

Exp:_________________

Quantity________________

Exp:_________________

Quantity________________

No___
No___

IV tubing and needles (adult)

Yes___

No___

Buckets/Containers for ORS mixing

Yes___

No___

1L container for ORS dispensing

Yes___

No___

Public reporting burden of this collection of information is estimated to average 15 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)

Interviewer____________________
Health Facility ID_________________

Version 3: 5 July 2015
OMB No. 0920-1011
Exp Date: 3 March 2017

LAB SUPPLIES
Rapid cholera test kits

Yes___

No___

Rectal swabs

Yes___

No___

Cary-Blair medium

Yes___

No___

Exp:_________________

Quantity________________

Exp:_________________

Quantity________________

Exp:_________________

Quantity________________

Exp:_________________

Quantity________________

Exp:_________________

Quantity________________

Exp:_________________

Quantity________________

Exp:_________________

Quantity________________

WATER, SANITATION, & HYGIENE
Chlorine/bleach solution or powder
(for cleaning)
Drinking water treatment supplies
(i.e. Aquatabs)
Gloves
Hand sanitizing Gel

Yes___
Yes___
Yes___
Yes___

No___
No___
No___
No___

WATER SOURCE
Water source on HCF premises?

Yes___

No___

If yes, is water currently available? ________________
If no, how many meters from HCF?_________________

HANDWASHING STATIONS
Department

Handwashing Station?

If yes, water available?

If yes, soap available?

Outpatient Department

Yes___ No___ N/A___

Yes___

No___

Yes___

No___

Casualty/Emergency Department

Yes___ No___ N/A___

Yes___

No___

Yes___

No___

Cholera Isolation Unit

Yes___ No___ N/A___

Yes___

No___

Yes___

No___

Pediatric Department

Yes___ No___ N/A___

Yes___

No___

Yes___

No___

Maternity Department

Yes___ No___ N/A___

Yes___

No___

Yes___

No___

Medicine Department

Yes___ No___ N/A___

Yes___

No___

Yes___

No___

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)

Interviewer____________________
Health Facility ID_________________

Version 3: 5 July 2015
OMB No. 0920-1011
Exp Date: 3 March 2017

GUIDELINES & PROTOCOLS
Guideline

Available? Y/N

Year published

Water, Sanitation, & Hygiene

Yes___

No___

Year______________

Infection Prevention & Control

Yes___

No___

Year______________

Cholera Management & Treatment

Yes___

No___

Year______________

IDSR Technical Guidelines

Yes___

No___

Year______________

Written by
(i.e MOH, WHO, MSF)

___________________
___________________
___________________
___________________
Clinician’s Handbook

Yes___

No___

Year______________

___________________
MOH 505 Integrated Disease
Surveillance & Response Weekly
Summary Reporting Register

Yes___

No___

Year______________

___________________

CHOLERA REPORTING
If yes, number of cholera cases by week (from MOH 505 register)
Epidemiological Week

Dates by week

1

Dec 29 – Jan 4

Number of cases

_______________
2

Jan 5 – Jan 11

_______________
3

Jan 12 – Jan 18

4

Jan 19 – Jan 25

5

Jan 26 – Feb 1

6

Feb 2 – Feb 8

_______________
_______________
_______________
_______________
7

Feb 9 – Feb 15

_______________
8

Feb 16 – Feb 22

_______________
9

Feb 23 – Mar 1

10

Mar 2 – Mar 8

_______________
_______________
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)

Interviewer____________________
Health Facility ID_________________

Version 3: 5 July 2015
OMB No. 0920-1011
Exp Date: 3 March 2017

11

Mar 9 – Mar 15

12

Mar 16 – Mar 22

_______________
_______________
13

Mar 23 – Mar 29

_______________
14

Mar 30 – Apr 5

_______________
15

Apr 6 – Apr 12

16

Apr 13– Apr 19

17

Apr 20 – Apr 26

18

Apr 27 – May 3

_______________
_______________
_______________
_______________
19

May 4 – May 10

_______________
20

May 11 – May 17

_______________
21

May 18 – May 24

22

May 25 – May 31

23

Jun 1 – Jun 7

24

Jun 8 – Jun 14

25

Jun 15 – Jun 21

_______________
_______________
_______________
_______________
_______________
26

Jun 22 – Jun 28

_______________
27

Jun 29 – Jul 5

_______________
28

Jul 6 - 12

29

Jul 13 - 19

_______________
_______________

NAIROBI: CHLORINE TESTING (ask if you are permitted to test the water supply at the HCF for chlorine)
Free Chlorine Residual
((measured by Hach Pocket Chlorimeter)

Turns pink: Yes___
__.__mg/L

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)

No___

Form Approved
OMB No. 0920-1011
Exp. Date 03/31/2017

Monkeypox Risk Assessment Form
Republic of Congo, 2015

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)

Date de l’interview :

Numéro de l’interview :

Educateur conduisant l’interview :
Educateur écrivant les réponses :
Département de :
Village :
Sexe :

Durée dans le village :
Mâle

Occupation :

Femelle

Age :

(ans)

Agriculteur
Étudiant
Chasseur
Enfant
Ménagère / Maison employé
Marchand

Personnel de la santé

1. Quelles sont et combien d’animaux domestique et/ou sauvage possédez-vous dans votre ménage?
Espèce

Oui
(Cocher)

Si oui, combien
de chaque espèce

Singe
Porc
Chèvre
Bovin
Canard
Autres

Espèce

Oui
(Cocher)

Si oui, combien
de chaque espèce

Volaille
Chien
Mouton
Chat
Pigeons
Cobaye

_____ J’ai pas des animaux
2. Combien de personne habite votre ménage?
_____a- combien sexe féminin
_____b- combien sexe male
3. De quelle matière est faite de votre sol?
_____a- Terre
_____b- Ciment
_____c- Pavé
_____d- Autres
4. De quelle matière est faite de votre murs?
_____a- Boue
_____b- Bois
_____c- Brique
_____d- Écorce
_____e- Autres
(Expliquer) ________________
5. De quelle matière est faite de votre toiture?
_____a-Chaum
_____b- Tôle métallique (ferre)
_____c- Autres
(Expliquer) ________________
6. De quelle matière est faite de votre fenêtres et ports?
_____a- Planche
_____b- Tôle métallique (ferre)
_____c- Bois
_____d- Les tiges de palmier
_____e- Autres
(Expliquer) ________________

2

Singe
Cercopithèque noir et vert
Cercopithèque ascagne
Cercopithèque de Brazza
Guéréza d'Angola
Bonobo
Rongeur
Rongeur de foret
Rongeur de maison
Cricetomys de foret
Grand aulacode
Écureuil
Écureuil de bois
Écureuil volant
Heliosciure a pattes rose
Grand écureuil
Atherure
Pangolin

Vendre

Mange

Dépece

Chassé

Espèces

Trouve

Vendre

Mange

Dépece

Chassé

Espèce

Trouve

7. Quelles types d’animaux avez-vous étiez en ce dernier mois? Cocher les cases appropriée.

Chèvre
Sanglier
Potamochère
Chevrotin
aquatique/biche-cochon
Céphalophe
Céphalophe a franc noir
Céphalophe de Peters
Céphalophe dorsalis
Céphalophe syvicultor
Céphalophe bleu
Genette
Léopard
Mangouste
Volaille
Serpent
Tortue
Crocodile
Éléphant
Autres

_____ Je ne chasse pas des animaux de la brousse
_____ Je ne dépece pas des animaux de la brousse
_____ Je ne mange pas des animaux de la brousse

8. Qui avait la charge de préparer cette viande?
_____a- Femmes
_____b- Anciennes femmes
_____c- Hommes
_____d- Jeunes hommes
_____e- Jeunes femmes
_____f- Chef de ménage
_____g- Femme/copine
_____h- Mére de l’enfant
9. Combien de jour dans le mois les enfants dans votre ménage vont-ils à l’école?
_____a- Jamais
_____b- Moins 1 fois par semaine
_____c- 2 fois par semaine
_____d- 3 fois par semaine
_____e- 4 fois par semaine
_____f- Plus de 5 fois par semaine
_____g- Je ne sais pas
_____h- Pas des enfants dans mon ménage
10. Combien de jour dans le mois allez-vous à l’église ou à la mosquée?
_____a- Jamais
_____b- Moins 1 fois par semaine
_____c- 2 fois par semaine
_____d- 3 fois par semaine
_____e- 4 fois par semaine
_____f- Plus de 5 fois par semaine

3

_____g- Je ne sais pas
11. Combien de jour dans le mois allez-vous en forêt?
_____a- Jamais
_____b- Moins 1 fois par semaine
_____c- 2 fois par semaine
_____d- 3 fois par semaine
_____e- 4 fois par semaine
_____f- Plus de 5 fois par semaine
_____g- Je ne sais pas
12. Quelles activités faites-vous dans la forêt?
_____a- Chassé
_____c- Ramasser bois de chauffage
_____e- Recueillir l'eau
_____b- Agriculture
_____d- Cueillette
_____f- Autres

4

(Expliquer)______________________________
13. Combien de jour dans le mois allez-vous au marché?
_____a- Jamais
_____b- Moins 1 fois par semaine
_____c- 2 fois par semaine
_____d- 3 fois par semaine
_____e- 4 fois par semaine
_____f- Plus de 5 fois par semaine
_____g- Je ne sais pas
14. Quels types d’animaux entre dans la chambre/maison ou vous dormez (la journée ou la nuit)?
Cocher les cases appropriée.
Espèce
Singe
Souris
Athrure
Graphiure (loir)
Rat de gambie

Oui
(Cocher)

Espèce

Oui
(Cocher)

Écureuil
Pangolin
Porc
Rat
Insectes

Espèce
Grand aulacode
Serpent
Volaille
Chèvre
Autres

_____ Aucune animal n’entre dans ma chambre/maison
15. Est-ce que les rongeurs mordent les enfants ou les adultes dans votre ménage?
___________Oui
___________Non
__________Je ne sais pas
16. Avez-vous déjà trouvé un singe mort en forêt?
___________Oui
___________Non

__________Je ne sais pas

Si oui, qu’avez-vous fait de lui?
_____ a- Le manger
_____b- Le ramasser
_____ c- Le manipuler
_____d- Le laisser

Oui
(Cocher)

Case ID: ____________
ABSTRACTION FORM – NTM INFECTIONS
Abstractor: _____________________________________

Date of abstraction: ____ / ____ / ____

Case ID: _____________
This patient is a:

1 [ ] Case

Pathogen

2 [ ] Control

Infection site

Specimen

Date specimen

Test performed

obtained
[ ] MAI

[ ] Blood

[ ] Blood

[ ] other slow growing

[ ] Surgical site

[ ] Tissue/Biopsy

mycobacterium

[ ] Skin/soft tissue [ ] BAL/BW

[ ] Histopath

[ ] M.

[ ] Respiratory

[ ] Urine

[ ] HPLC

abscessus/chelonae

[ ] Pleural fluid

[ ] drainage

[ ] Molecular

[ ] Other______

[ ] Other______

[ ] M. fortuitum/goodii [ ] Urinary
[ ] other rapid

[ ] Abscess

growing

[ ] Other_______

_ _/_ _/_ _

[ ] Culture
[ ] PCR

mycobacterium

5 years prior to positive culture date: __ __ / __ __ / __ __
Did the patient have prior surgery within 5 years prior to positive NTM lab result? Y N
Surgery type: cardiothoracic orthopedic abdominal gyn other_______________
Date __ __/ __ __ / __ __
Surgery type: cardiothoracic orthopedic abdominal gyn other_______________
Date __ __/ __ __ / __ __
A. Patient information
Sex: 1 [ ] Male

2 [ ] Female

9 [ ] N/A

Year of birth: __________
Race/Ethnicity:
Race:

White

Black

Asian

American Indian or Alaska Native

Other____________

Native Hawaiian or Other Pacific Islander

Ethnicity:

Hispanic/Latino

Non-Hispanic/Latino

B. History and Physical (Prior to surgery if the patient had a surgery or prior to positive culture
if no previous surgery)
Page 1 of 7

Case ID: ____________
Patient medical history:
[ ] CAD
[ ] Rheumatoid Arthritis
[ ] PVD

[ ] Solid tumor

[ ] CHF

[ ] Connective tissue disease

[ ] Hematologic malignancy [ ] Liver disease [ ] PUD

[ ] Chronic pulmonary disease [ ] Diabetes w/o complications [ ] AIDS (CD4<200 or OI)
[ ] Diabetes w/end organ disease

[ ] Inflammatory bowel disease

[ ] Moderate to severe renal disease (Cr>=3.0, h/o uremia, transplant)
[ ] Obesity

[ ] Hypertension

[ ] Ulcer disease

[ ] Cystic fibrosis

Other:__________________________________________________________________
Smoking status (at admission) 1 [ ] Yes, amount (pack-years):_____2 [ ] No 9 [ ] Unknown
Any prior history of smoking? 1 [ ]Yes, pack-year history ____ [ ] No 9 [ ] Unknown
Other history (i.e. other pertinent medical or surgical history):
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
C. Hospital course- Refers to patient’s hospitalization regarding the positive culture recorded on
page 1. The patient may have been hospitalized for something else and then developed infection, or
hospitalized to treat the infection.
Was patient hospitalized? Y N
If no, skip section C.
Admission date: __ __/__ __/__ __ Discharge date: __ __/__ __/__ __
Admission diagnosis: ______________________________________________
Abx used within 7 days prior to cx 1 [ ] Yes
2 [ ] No
9 [ ] Unknown
If Yes, start date__ __/__ __/__ __ and drug name______________________
Name
Route
Start date
End date
_____________
[ ] IV [ ] IM [ ] __ __ /__ __/__ __ __ /__
PO
__
__/__ __
_____________
[ ] IV [ ] IM [ ] __ __ /__ __/__ __ __ /__
PO
__
__/__ __
_____________
[ ] IV [ ] IM [ ] __ __ /__ __/__ __ __ /__
PO
__
__/__ __
_____________
[ ] IV [ ] IM [ ] __ __ /__ __/__ __ __ /__
PO
__
__/__ __
Onset of infectious symptoms:

Page 2 of 7

Case ID: ____________
Infectious symptoms in the 48 hours prior to or after positive culture:
Fever
Chills
Abdominal pain
Cough
Hemoptysis
Dyspnea
Respiratory failure
Shock

1 [ ] Yes
1 [ ] Yes
1 [ ] Yes
1 [ ] Yes
1 [ ] Yes
1 [ ] Yes
1 [ ] Yes
1 [ ] Yes

2 [ ] No
2 [ ] No
2 [ ] No
2 [ ] No
2 [ ] No
2 [ ] No
2 [ ] No
2 [ ] No

9 [ ] Unknown
9 [ ] Unknown
9 [ ] Unknown
9 [ ] Unknown
9 [ ] Unknown
9 [ ] Unknown
9 [ ] Unknown
9 [ ] Unknown

1. Did the patient have a wound? Y N
If patient had a wound during the hospitalization of interest:
Wound infection: 1 [ ] Superficial 2 [ ] Deep 3 [ ] Organ space [ ] Unknown
Site of the wound infection _____________ 9 [ ] Unknown
Drainage
Swelling
Erythema
Pain

1 [ ] Yes
1 [ ] Yes
1 [ ] Yes
1 [ ] Yes

2 [ ] No
2 [ ] No
2 [ ] No
2 [ ] No

Other symptoms:_________________________________________________________________
Surgical Debridement 1 [ ] Yes

2 [ ] No

Wound Classification (only if surgically addressed):
□ Clean □ Clean-Contaminated □ Contaminated

Date

__ __ /__ __/__ __

□ Dirty

Patient treatment and outcome of index hospitalization:
Antibiotic received
Name
______________
______________
______________

Route
[ ] IV [ ] IM [ ] PO
[ ] IV [ ] IM [ ] PO
[ ] IV [ ] IM [ ] PO

Dose
_________
_________
_________

Date start
_ _/_ _/_ _
_ _/_ _/_ _
_ _/_ _/_ _

Patient outcome of this hospitalization?
1 [ ] Recover and discharged 2 [ ] Died 3 [ ] Still in hospital
4 [ ] Other____________________ 9 [ ] Unknown

Page 3 of 7

Date stop
_ _/_ _/_ _
_ _/_ _/_ _
_ _/_ _/_ _

Case ID: ____________
D. Previous surgery: If the patient had a surgery in the 5 years prior to positive culture, complete
section D for each surgery.
Date of surgery __ __/__ __/__ __ Surgical Procedure: ________________________________
Admission date: __ __/__ __/__ __ Discharge date: __ __/__ __/__ __

Absolute neutrophil count <50 (day of surgery): Y N UNK

Date: __ __/__ __/__ __

Highest glucose in 48 hours prior to surgery:_________ Date: __ __/__ __/__ __
HgbA1c value within 3 months of surgery (take most recent value):______Date: __ __/__ __/__ __
Patient location/movements during hospitalization:
Unit

Room

Date in

Date out

Surgical Details:
Any special skin preparation (e.g. hair removal and chlorhexidine baths): ____________________
______________________________________________________________________________
If this is a CABG, what is the harvest site_____________________________
Surgery start time:___________
Surgery stop time:___________
OR Room #: ______
Surgeon ________________________

Anesthesiologist _________________________

PA-C ____________________________

CRNA _________________________

Perfusionist ________________________ Scrub Nurse(s)___________________
Circulator 1 _______________________

Circulator 2_________________________

Other (name/title)__________________

Other (name/title)_________________________
Page 4 of 7

Case ID: ____________

Did patient have Cardiopulmonary Bypass (CBP)? 1 [ ] Yes 2 [ ] No 9 [ ] Unknown
Was a CBP machine present in the surgical room but not used? 1 [ ] Yes 2 [ ] No 9 [ ] Unknown
On pump time: ____
Intraoperative US (e.g., TEE) performed:

1 [ ] Yes 2 [ ] No 9 [ ] Unknown

Other drugs during surgery?
Type

Route
[ ] IV
[ ] IV
[ ] IV
[ ] IV
[ ] IV

[ ] IM
[ ] IM
[ ] IM
[ ] IM
[ ] IM

[ ] topical
[ ] topical
[ ] topical
[ ] topical
[ ] topical

Transfusions during surgery?
Type (PRBc/cryp/FFP)

Units

Donor vs. Analogous

Highest glucose during procedure: ____________
Line insertion perioperative:
Date inserted
Type
__ __/__ __/__ __
[ ] CVC
[ ] PICC
[ ] Port
[ ] Swan-Ganz
[ ] A line
[ ] Other___________
__ __/__ __/__ __
[ ] CVC
[ ] PICC
[ ] Port
[ ] Swan-Ganz
[ ] Other___________
__ __/__ __/__ __
[ ] CVC
[ ] PICC
[ ] Port
[ ] Swan-Ganz
[ ] Other___________

Date removed
__ __/__ __/__ __

__ __/__ __/__ __

__ __/__ __/__ __

Page 5 of 7

Case ID: ____________
List all the devices or equipment that were inserted into patient’s body (valve, grafts, drains,
staple/suture, wound dressing…)

Graft

Name

Catalog #

Serial #

Check if
left in
place

Staples/sutures

prosthetics

Drains

dressing

Were additional cooling methods used? Y N UNK
What type? ____________________________________________
Other intra-operative findings (including drugs in/on chest, hemostatic agents): _______________
________________________________________________________________________________

Page 6 of 7

Case ID: ____________
Post-operative:
Medications (suppressors, immunosuppressant) after surgery?
Type

Dose

Route
[ ] IV
[ ] IV
[ ] IV
[ ] IV

Date and time start

Date and time stop

[ ] IM
[ ] IM
[ ] IM
[ ] IM

Highest glucose within 24 hours post operation: ______________ Date: __ __/__ __/__ __
Wound care after surgery:
Dressing change (one change per line, regardless of products used) or wound cleansing
Dressing/cleansing
product

Date change

Time change

Staff name

Note

Urinary catheter information:
Date inserted
__ __/__ __/__ __

Date withdrawn
__ __/__ __/__ __

__ __/__ __/__ __

__ __/__ __/__ __

Type
[ ] Urinary catheter
[ ] Suprapubic catheter
[ ] Intermittent catherization
[ ] Other___________
[ ] Urinary catheter
[ ] Suprapubic catheter
[ ] Intermittent catherization
[ ] Other___________

Date of dressing removal: __ __ /__ __/__ __ [ ] N/A
Date of staple/suture removal: __ __ /__ __/__ __ [ ] N/A
Date of drain removal: __ __ /__ __/__ __ [ ] N/A
Other interventions in or around the wound (date) _______________________________________
Did patient have a shower during hospitalization after surgery? [ ] Yes
Date shower 1: __ __/__ __/__ __
Date shower 2: __ __/__ __/__ __
Date shower 3: __ __/__ __/__ __

Page 7 of 7

[ ] No

CDC ID _____
First NTM+ Culture (or Index Date): ___/____/______ Study Period: ____/____/______ - ____/____/_______
(index date-3.5 years)

Random Control Surgery date: ____/_____/_______
MEDICAL HISTORY

Birthday: ____/____/______

Gender:

Male

Female

Race:

White

Black

Ethnicity:

Hispanic

Non-Hispanic

History of prior NTM infection?
Chronic Lung Disease

Y / N

COPD

Y / N

(index date -30days)

Other, specify____________
Y

N
Immunocompromised?

Y/ N

AIDS/HIV (CD4<200)

Y / N

Cystic Fibrosis Y / N

Organ/Heme Transplant

Y / N

Sarcoidosis

Y / N

Chemotherapy (in last 3.5yrs)

Y / N

Y / N

Systemic Steroids (in last 3.5yrs)

Y / N

Diabetes
Admission

Other immunocompromising meds/conditions/risk factors

[ ] <24 hours prior to surgery

If so, specify: __________________________________________________

Y / N

[ ] >24 hours prior to surgery
OUTCOMES
Death
If so, related to surgery

Y / N

Any Post-Op Infection (not just NTM)

Y / N

Y / N

Surgical site infection

Y / N

Systemic infection

Y / N

If so, related to NTM infection Y / N
If so, reason for death _________________

If so, location of infection ___________________

FOR CASES ONLY
Organism: __________________________
MAI

Y / N

Date of first NTM culture ____/____/_______

other slow growing NTM

Y / N

rapid growing NTM

Y / N

Number of specimen growing NTM ______
Specimen site of NTM+ cultures
Respiratory

Y / N

Blood

Deep tissue/fluid

Y / N

if so, specify from where _____________________

Superficial tissue/fluid Y / N

if so, specify from where_____________________

Y / N

if so, specify _______________________________

Other

Clinical symptoms associated with NTM culture

Y / N

Y / N

Pneumonia/lung/respiratory

Y / N

Bloodstream infection/disseminated

Deep/organ space

Y / N

Superficial skin/soft tissue/surgical site

Treatment with antibiotics

Y / N
Y / N

Y / N

1 Primary Procedure: _______________________________ Surgery Type

_________ Laparoscopic vs Open

Proc #2: ____________________________________ Proc #3: ____________________________________

Date ____/_____/______ Start time: _______ End time: ________
Intubation

Central Line in OR

Y / N

Bypass operational in room
Implant (any devices)

Y / N

Y / N

Minutes: ________ OR number: _________
Chest tubes in OR

Y / N

If yes, time on pump ___________
Valve

Y / N

Graft

Y / N

Circ arrest

Y / N
Y / N

specify ________________

Topical meds applied to wound in OR ____________________________________________________________
STAFF

Perfusionist: __________________________________

Surgeon: ________________________________

Anesthesiologist: _______________________________

Scrub Nurse: ____________________________

Circulating Nurse: _______________________________

Intra-Op Complications
Incident Report

Y / N

If yes, specify _________________________________________

Y / N

If yes, specify _________________________________________

Pre-Op Diagnosis ____________________________

Post-Op Condition ______________________________

Primary dressing removal _____/______/_________ Final Chest tube removal _____/_____/________
Shower before discharge:

Y / N

wounds at discharge

Discharge date: ____/____/________

Y / N

status of wound at discharge _____________________________

Other: _______________________________________________________________________________________

2 Primary Procedure: _______________________________

Surgery Type _________ Laparoscopic vs Open

Proc #2: ____________________________________ Proc #3: ____________________________________
Date ____/_____/________ Start time: ____________ End time: _____________
Intubation

Central Line in OR

Y / N

Bypass operational in room
Implant (any devices)

Y / N

Y / N

OR number: _________

Chest tubes in OR

Y / N

If yes, time on pump ___________
Valve

Y / N

Graft

Y / N

Circ arrest

Y / N
Y / N

specify ________________

Topical meds applied to wound in OR ____________________________________________________________
STAFF

Perfusionist: __________________________________

Surgeon: ________________________________

Anesthesiologist: _______________________________

Scrub Nurse: ____________________________

Circulating Nurse: _______________________________

Intra-Op Complications
Incident Report

Y / N
Y / N

If yes, specify ________________________________________
If yes, specify ________________________________________

Pre-Op Diagnosis ____________________________

Post-Op Condition ____________________________

Primary dressing removal _____/______/_________

Final Chest tube removal _____/_____/________

Shower before discharge:

Y / N

Discharge date: ____/____/________

wounds at discharge

Y / N

status of wound at discharge _____________________________

Other: _______________________________________________________________________________________

3 Primary Procedure: _______________________________ Surgery Type

_________ Laparoscopic vs Open

Proc #2: ____________________________________ Proc #3: ____________________________________
Date ____/_____/______ Start time: _______ End time: ________
Intubation

Y / N

Central Line in OR

Y / N

Minutes: ________ OR number: _________
Chest tubes in OR

Y / N

Bypass operational in room
Implant (any devices)

Y / N

Y / N

If yes, time on pump ___________
Valve

Y / N

Graft

Y / N

Circ arrest

Y / N

specify ________________

Topical meds applied to wound in OR ____________________________________________________________
STAFF

Perfusionist: __________________________________

Surgeon: ________________________________

Anesthesiologist: _______________________________

Scrub Nurse: ____________________________

Circulating Nurse: _______________________________

Intra-Op Complications
Incident Report

Y / N

If yes, specify _________________________________________

Y / N

If yes, specify _________________________________________

Pre-Op Diagnosis ____________________________

Post-Op Condition ______________________________

Primary dressing removal _____/______/_________ Final Chest tube removal _____/_____/________
Shower before discharge:

Y / N

wounds at discharge

Discharge date: ____/____/________

Y / N

status of wound at discharge _____________________________

Other: _______________________________________________________________________________________

4 Primary Procedure: _______________________________

Surgery Type _________ Laparoscopic vs Open

Proc #2: ____________________________________ Proc #3: ____________________________________
Date ____/_____/________ Start time: ____________ End time: _____________
Intubation

Central Line in OR

Y / N

Bypass operational in room
Implant (any devices)

Y / N

Y / N

OR number: _________

Chest tubes in OR

Y / N

If yes, time on pump ___________
Valve

Y / N

Graft

Y / N

Circ arrest

Y / N
Y / N

specify ________________

Topical meds applied to wound in OR ____________________________________________________________
STAFF

Perfusionist: __________________________________

Surgeon: ________________________________

Anesthesiologist: _______________________________

Scrub Nurse: ____________________________

Circulating Nurse: _______________________________

Intra-Op Complications
Incident Report

Y / N

If yes, specify ________________________________________

Y / N

If yes, specify ________________________________________

Pre-Op Diagnosis ____________________________

Post-Op Condition ____________________________

Primary dressing removal _____/______/_________

Final Chest tube removal _____/_____/________

Shower before discharge:

Y / N

wounds at discharge

Discharge date: ____/____/________

Y / N

status of wound at discharge _____________________________

Other: _______________________________________________________________________________________

5 Primary Procedure: _______________________________ Surgery Type

_________ Laparoscopic vs Open

Proc #2: ____________________________________ Proc #3: ____________________________________
Date ____/_____/______ Start time: _______ End time: ________
Intubation

Central Line in OR

Y / N

Bypass operational in room
Implant (any devices)

Y / N

Y / N

Minutes: ________ OR number: _________
Chest tubes in OR

Y / N

If yes, time on pump ___________
Valve

Y / N

Graft

Y / N

Circ arrest

Y / N
Y / N

specify ________________

Topical meds applied to wound in OR ____________________________________________________________
STAFF

Perfusionist: __________________________________

Surgeon: ________________________________

Anesthesiologist: _______________________________

Scrub Nurse: ____________________________

Circulating Nurse: _______________________________

Intra-Op Complications
Incident Report

Y / N

If yes, specify _________________________________________

Y / N

If yes, specify _________________________________________

Pre-Op Diagnosis ____________________________

Post-Op Condition ______________________________

Primary dressing removal _____/______/_________ Final Chest tube removal _____/_____/________
Shower before discharge:

Y / N

wounds at discharge

Discharge date: ____/____/________

Y / N

status of wound at discharge _____________________________

Other: _______________________________________________________________________________________

6 Primary Procedure: _______________________________

Surgery Type _________ Laparoscopic vs Open

Proc #2: ____________________________________ Proc #3: ____________________________________
Date ____/_____/________ Start time: ____________ End time: _____________
Intubation

Central Line in OR

Y / N

Bypass operational in room
Implant (any devices)

Y / N

Y / N

OR number: _________

Chest tubes in OR

Y / N

If yes, time on pump ___________
Valve

Y / N

Graft

Y / N

Circ arrest

Y / N
Y / N

specify ________________

Topical meds applied to wound in OR ____________________________________________________________
STAFF

Perfusionist: __________________________________

Surgeon: ________________________________

Anesthesiologist: _______________________________

Scrub Nurse: ____________________________

Circulating Nurse: _______________________________

Intra-Op Complications
Incident Report

Y / N

If yes, specify ________________________________________

Y / N

If yes, specify ________________________________________

Pre-Op Diagnosis ____________________________

Post-Op Condition ____________________________

Primary dressing removal _____/______/_________

Final Chest tube removal _____/_____/________

Shower before discharge:

Y / N

wounds at discharge

Discharge date: ____/____/________

Y / N

status of wound at discharge _____________________________

Other: _______________________________________________________________________________________

7 Primary Procedure: _______________________________ Surgery Type

_________ Laparoscopic vs Open

Proc #2: ____________________________________ Proc #3: ____________________________________
Date ____/_____/______ Start time: _______ End time: ________
Intubation

Central Line in OR

Y / N

Bypass operational in room
Implant (any devices)

Y / N

Y / N

Minutes: ________ OR number: _________
Chest tubes in OR

Y / N

If yes, time on pump ___________
Valve

Y / N

Graft

Y / N

Circ arrest

Y / N
Y / N

specify ________________

Topical meds applied to wound in OR ____________________________________________________________
STAFF

Perfusionist: __________________________________

Surgeon: ________________________________

Anesthesiologist: _______________________________

Scrub Nurse: ____________________________

Circulating Nurse: _______________________________

Intra-Op Complications
Incident Report

Y / N

If yes, specify _________________________________________

Y / N

If yes, specify _________________________________________

Pre-Op Diagnosis ____________________________

Post-Op Condition ______________________________

Primary dressing removal _____/______/_________ Final Chest tube removal _____/_____/________
Shower before discharge:

Y / N

wounds at discharge

Discharge date: ____/____/________

Y / N

status of wound at discharge _____________________________

Other: _______________________________________________________________________________________

8 Primary Procedure: _______________________________

Surgery Type _________ Laparoscopic vs Open

Proc #2: ____________________________________ Proc #3: ____________________________________
Date ____/_____/________ Start time: ____________ End time: _____________
Intubation

Central Line in OR

Y / N

Bypass operational in room
Implant (any devices)

Y / N

Y / N

OR number: _________

Chest tubes in OR

Y / N

If yes, time on pump ___________
Valve

Y / N

Graft

Y / N

Circ arrest

Y / N
Y / N

specify ________________

Topical meds applied to wound in OR ____________________________________________________________
STAFF

Perfusionist: __________________________________

Surgeon: ________________________________

Anesthesiologist: _______________________________

Scrub Nurse: ____________________________

Circulating Nurse: _______________________________

Intra-Op Complications
Incident Report

Y / N

If yes, specify ________________________________________

Y / N

If yes, specify ________________________________________

Pre-Op Diagnosis ____________________________

Post-Op Condition ____________________________

Primary dressing removal _____/______/_________

Final Chest tube removal _____/_____/________

Shower before discharge:

Y / N

wounds at discharge

Discharge date: ____/____/________

Y / N

status of wound at discharge _____________________________

Other: _______________________________________________________________________________________

9 Primary Procedure: _______________________________ Surgery Type

_________ Laparoscopic vs Open

Proc #2: ____________________________________ Proc #3: ____________________________________
Date ____/_____/______ Start time: _______ End time: ________
Intubation

Central Line in OR

Y / N

Bypass operational in room
Implant (any devices)

Y / N

Y / N

Minutes: ________ OR number: _________
Chest tubes in OR

Y / N

If yes, time on pump ___________
Valve

Y / N

Graft

Y / N

Circ arrest

Y / N
Y / N

specify ________________

Topical meds applied to wound in OR ____________________________________________________________
STAFF

Perfusionist: __________________________________

Surgeon: ________________________________

Anesthesiologist: _______________________________

Scrub Nurse: ____________________________

Circulating Nurse: _______________________________

Intra-Op Complications
Incident Report

Y / N

If yes, specify _________________________________________

Y / N

If yes, specify _________________________________________

Pre-Op Diagnosis ____________________________

Post-Op Condition ______________________________

Primary dressing removal _____/______/_________ Final Chest tube removal _____/_____/________
Shower before discharge:

Y / N

wounds at discharge

Discharge date: ____/____/________

Y / N

status of wound at discharge _____________________________

Other: _______________________________________________________________________________________

10 Primary Procedure: _______________________________

Surgery Type _________ Laparoscopic vs Open

Proc #2: ____________________________________ Proc #3: ____________________________________
Date ____/_____/________ Start time: ____________ End time: _____________
Intubation

Central Line in OR

Y / N

Bypass operational in room
Implant (any devices)

Y / N

Y / N

OR number: _________

Chest tubes in OR

Y / N

If yes, time on pump ___________
Valve

Y / N

Graft

Y / N

Circ arrest

Y / N
Y / N

specify ________________

Topical meds applied to wound in OR ____________________________________________________________
STAFF

Perfusionist: __________________________________

Surgeon: ________________________________

Anesthesiologist: _______________________________

Scrub Nurse: ____________________________

Circulating Nurse: _______________________________

Intra-Op Complications
Incident Report

Y / N
Y / N

If yes, specify ________________________________________
If yes, specify ________________________________________

Pre-Op Diagnosis ____________________________

Post-Op Condition ____________________________

Primary dressing removal _____/______/_________

Final Chest tube removal _____/_____/________

Shower before discharge:

Y / N

Discharge date: ____/____/________

wounds at discharge

Y / N

status of wound at discharge _____________________________

Other: _______________________________________________________________________________________

CDC ID: ________
MRN: ___________
Is there evidence of prior NTM diagnosis or infection?

Y

N

When was prior NTM present? ____/____/________
Does patient have chronic lung issues?

Y

N

Does patient have COPD?

Y

N

Does patient have CF?

Y

N

Does patient have a chronic indwelling device? Y

N

PICC?

Y

N

Port?

Y

N

Dialysis fistula/graft?

Y

N

Dialysis catheter?

Y

N

Did the patient have an inpatient central line? Y

N

Is the patient immunocompromised?

Y

N

AIDS/HIV (CD4<200)?

Y

N

Solid/heme transplant?

Y

N

Chemo?

Y

N

Neutropenia?

Y

N

number of days: ________

Chronic systemic steroids (0.3mg/kg/day prednisone >3wk)?
Inherited immunocompromising condition
Other immunosuppressive meds?

Y

Y
N

If yes, specify: __________________________
Other NTM risk factors

Y

N

If yes, specify: _________________________
Number of NTM positive specimen: _____
First NTM+ specimen date: ____/_____/_________

Y
N

N

Type:

Respiratory

Deep tissue

Superficial Tissue

Blood

Other ___________

period of interest: ____/____/______ (3.5 yrs prior to cx) to ____/____/______ (30d prior to cx)
Last NTM+ specimen date: ____/_____/_________
Type:

Respiratory

Deep tissue

Superficial Tissue

Were any of the NTM+ specimen from:
Blood

Y

N

Superficial tissue/fluids

Y

N

If yes, what sites? ____________________
Deep tissue/fluids (organ space)

Y

N

If yes, what site? _____________________
Respiratory?

Y

N

Other sites?

Y

N

If yes, specify: _________________________
What NTM organisms grew in any NTM specimen?
MAC

Y

N

Other slow growing

Y

N

Rapid growing

Y

N

Did the NTM specimen grow other organisms? Y

N

If yes, specify: _____________________________________
Was there signs of clinical infection?

Y

N

Pneumonia/respiratory/lung?

Y

N

Endocarditis?

Y

N

Bloodstream infection/sepsis?

Y

N

Superficial (skin/soft tissue infection)? Y

N

Deep/organ space infection?

N

Y

Blood

Other ___________

Was the patient treated for NTM?

Y

N

Specify treatment: ___________________________________________
Date treatment started? ____/_____/_________
How many surgeries (3.5yrs-30days before positive culture): _______
Cardiothoracic surgeries?

Y

N

How many? _______

Gen surgery?

Y

N

How many? _______

Ortho?

Y

N

How many? _______

Other?

Y

N

How many? _______

How many admissions (3.5yrs-30days before positive culture): ______