Form Approved
OMB No. 0920-1011
Exp. Date 03/31/2017
Invasive GAS in LTCF 2015
Employee Survey
Date Completed: ____/____/____ □ Check box if documented case
A. Employee Background |
1. Study Number: ___ ___ ___ |
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2. Age: |
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3. Sex: Male Female |
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4. City of Residence: |
6. List occupation: RN/LPN CNA PT/OT RNA Housekeeping Dietary Physician Pharmacist Other __________________________ |
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5. State of Residence: |
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B. Job Description |
7. As part of your job, do you have physical contact with patients? Yes No |
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8. Areas usually worked: Patient rooms Nurses’ station Cafeteria Other _____________________ 9. Shifts usually worked: Day Evening Night Other________________________ 10. Patient units usually worked: 3W 2W 3E 2E Do not work in patient units All patient units 11. Which days do you usually work (circle ALL that apply): |
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12. What kind of patient contact do you have? (check ALL that apply) Give oral medications Feeding resident Respiratory therapy Tracheostomy care Change dressings/wound care Gastrostomy care Handle urinary catheter Bathe resident Assist with patient transfer Clean room Handle soiled linens/bedding Handle soiled diapers/bedpans Deliver meal trays Take vital signs |
C. Work Practice |
13. Do you use soap and water to clean your hands? Yes No 14. Do you use alcohol-based gel to clean your hands? Yes No |
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15. Please answer the following questions (circle answer) Never Always a. Do you wash your hands BEFORE physical contact with patients? 1 2 3 4 5 N/A b. Do you wash your hands AFTER physical contact with patients? 1 2 3 4 5 N/A c. Do you wash your hands BETWEEN contact with patients? 1 2 3 4 5 N/A d. Do you use the sink in the patient’s bathroom? 1 2 3 4 5 N/A e. Do you use the sink at the nurse’s station? 1 2 3 4 5 N/A f. Do you use gloves when changing bandages/dressing wounds? 1 2 3 4 5 N/A If yes, do you change gloves between patients/patient rooms? 1 2 3 4 5 N/A g. Do you use gloves when cleaning soiled patients or linens? 1 2 3 4 5 N/A If yes, do you change gloves between patients/patient rooms? 1 2 3 4 5 N/A h. Do you use gloves when bathing patients? 1 2 3 4 5 N/A |
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D. Your Health |
16. Do you have paid “Sick Leave”? Yes No 17. Did you receive prophylaxis for Group A Streptococcus infection? Yes No If yes, when? ______ / _______ / _______ |
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18 a. Since May 2, 2015, did you have a sore throat? Yes No (If no, skip to #19) b. When? ______ / _______ / _______ c. Were you diagnosed with strep throat? Yes No d. Did you miss work for this illness? Yes No How many days did you miss? ____________ e. How many days were you ill? _____________ f. Did you receive antibiotics for this condition? Yes No If yes, antibiotic name ___________________ |
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19 a. Since May 2, 2015, did you have a rash, open wound, or skin infection? Yes No (If no, skip to #20) b. When? ______ / _______ / _______ c. Did you miss work for this illness? Yes No How many days did you miss? ____________ d. How many days were you ill? _____________ e. Did you receive antibiotics for this condition? Yes No If yes, antibiotic name ___________________ f. What was your diagnosis? ____________________________ |
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20 a. Since May 2, 2015, did you have fever, cough, and/or other respiratory infection? Yes No (If no, skip to #21) b. When? ______ / _______ / _______ c. Did you miss work for this illness? Yes No How many days did you miss? ____________ d. How many days were you ill? _____________ e. Did you receive antibiotics for this condition? Yes No If yes, antibiotic name ___________________ f. What was your diagnosis? ____________________________ |
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21 a. How many people are in your household? __________ (If none, END) b. How many children under 18 years of age are in your household? _________ c. During the past 3 months, did anyone in your household have a sore throat? Yes No d. When? ______ / _______ / _______ e. Was he/she diagnosed with strep throat? Yes No f. Who? ____________ When? ______ / _______ / _______ g. Were they treated? Yes No If so, with what? ________________________________ h. During the past 3 months, did anyone in your household have impetigo or cellulitis (skin infections)? Yes No i. When? ______ / _______ / _______ |
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22 a. Do you work in another patient-care facility? Yes No (If no, skip to End) b. Name of facility: ______________________________________________ c. Have you been in contact with a patient infected with group A Strep in that facility? Yes No (If no, skip to End) d. When? ______ / _______ / _______ e. What was that patient’s diagnosis? Strep throat Impetigo Cellulitis Bacteremia Other __________________________________
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END – Thank you!
Public reporting burden of this collection of information is estimated to average 20 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74 Atlanta, Georgia 30333; ATTN: PRA (0920-1011)
File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
File Title | Group A Strep Investigation - 2003 |
Author | EPO |
File Modified | 0000-00-00 |
File Created | 2021-01-24 |