Healthcare Worker Questionnaire

Form Approved

OMB No. 0920-1011

Exp. Date 03/31/2017

Health Care Worker Questionnaire

HOSPITAL/HEALTH CENTER LEVEL DATA ONLY

Ask these questions of the medical officer, clinical officer, or nurse in charge.

The Ministry of Public Health and Sanitation is conducting a study on cholera. We would like to ask you some questions about your facility. We are wondering if you would be willing to answer some questions? Yes  continue No  If NO, thank them, and note on log sheet.

1. Respondent Name		_________________________
2. Title		_________________________
3. Location
4. Profession	1 2 3 4	Medical doctor Nurse Clinical officer Other (specify)____________
6. How many patients does this facility see in a day?
7. How many medical officers work here?
8. How many clinical officers work here?
9. How many nurses work here?
10. How many community health workers/patient attendants work here?
12. How many days of the week is this facility open?
13. How many hours per day is this facility open?
14. How many admission beds do you have?
15. What percentage of your patients go to a traditional healer before coming here?		__________%

Log books: all log books (in-patient and out-patient) added up :

How many people were seen at the hospital (in registration book) between November-December, 2009?
How many people of all ages were diagnosed with any diarrhea between November-December, 2009?
How many patients were diagnosed with cholera between November and December?
How many were >5 years of age?
How many were >2 years of age?
How many patients were diagnosed with cholera in November?
How many of these November cholera patients died?
How many of cholera patients that died were <5 years of age?
How many patients were diagnosed with cholera in December?
How many of these December cholera patients died?
How many of cholera patients that died were <5 years of age?
How many people were seen at the hospital (in registration book) in January, 2010?
How many people of all ages were diagnosed with any diarrhea in January?
How many patients were diagnosed with cholera in January?
How many were >5 years of age?
How many were >2 years of age?
How many of these January cholera patients died?
How many of cholera patients that died were <5 years of age?

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)