Form Approved
OMB No. 0920-1011
Exp Date 3/31/17
HEALTHCARE WORKER
RABIES EXPOSURE QUESTIONNAIRE
Last Name:___________________________________ First Name: _______________________
Address: _____________________________________ Home Phone # (_____) _____________
Work Phone# (_____) _____________
City: ________________________________________ Zip Code: ________________________
Age _____________ (years)
Sex: M F
In which department do you work? ___________________________________________
What is your job title? _____________________________________________________
Describe your job: ________________________________________________________
Did you have any physical contact with the patient, his bodily secretions, laboratory specimens, or tissue?
No _________ Yes __________
About how much time did you spend with the patient? ____________________ (hours)
Were you bitten by the patient? No ______ Yes _____
Were you kissed by the patient? No ______ Yes _____
Were you in contact with any of the patient’s fluids or secretions listed below? (Check each selection that applies)
If YES, was it on:
Bare Skin Gloves, Etc.
Saliva No ___ Yes ___ _____ _____
Respiratory secretions No ___ Yes ___ _____ _____
Cerebrospinal fluid No ___ Yes ___ _____ _____
Tears No ___ Yes ___ _____ _____
Did you have a fresh wound, cut or other break in skin that may have been in contact with the patient’s oral secretions?
No _____ Yes_____
If YES: Location of wound/cut break ________________________________________
Which secretions?
Saliva _____
Respiratory secretions _____
Cerebrospinal fluid _____
Tears _____
Did any of the patient’s oral secretions come in contact with your eyes, mouth, or nose (mucous membranes)?
No _____ Yes_____
If YES: Describe secretions, mucous membranes & circumstances.
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
Did you participate in any procedure performed on the patient? (Include intubation, lumbar puncture, nasogastric tube insertion)
No _____ Yes_____
If YES: Which procedure: __________________________________________________
What personal protective equipment did you use? ________________________________
Did you have any breaks in your gloves?
No _____ Yes_____
In your opinion, what was your most significant exposure? What was the exposure you are most concerned about?
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
Have you previously been immunized against rabies?
No _____ Yes_____
If YES: When? (Month/Year) ______/______
Why were you immunized? _________________________________________________
Which vaccine? __________________________________________________________
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)
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Title | RABIES POST EXPOSURE PROPHYLAXIS SCHEDULE |
| Author | Jon Rosenberg, M.D. |
| File Modified | 0000-00-00 |
| File Created | 2021-01-24 |