Inventory of ICs - Y2Q3

Appendix 2. Data Collection Forms.pdf

Emergency Epidemic Investigation Data Collections - Expedited Reviews

Inventory of ICs - Y2Q3

OMB: 0920-1011

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0920-1011 can be found here:

Document [pdf]

Download: pdf | pdf

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

HIV Risk Factors Interview Guide

Public reporting burden of this collection of information is estimated to average 90 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)

HIV in SE Indiana Exploratory Study

Version: 08/27/2015

QUALITATIVE INTERVIEW TRACKING FORM

To be completed by the interviewer at the time of screening for eligibility:
Date of screening
Name of interviewer/recruiter
How recruited?
Screening Interview Questions

Participant must answer the following for
eligibility

1. How old are you?

1. Must be 18 years or older

Participant
response

2. Do you currently live in [County Name]
2. Must be yes.
County?
3. When was the last time you injected
3. Must be within the previous 12
drugs?
months.
4. Screen for IDU status. Injection marks
4. Where on your body do you usually
or NEP card (next question) are both
inject?
acceptable.
5. Have you ever used the Needle
5. Any answer is fine, aim for a mix.
Exchange Program here in [County
Name] County?
6. Did you participate in the group
6. Try not to have too many repeats from
research at the H20 Church in July?
the focus groups, but some are ok.
Note to Interviewer: Aim for a balance in the number of women and men.

Eligible?

Yes

No (stop the interview)

To be completed by the interviewer at the beginning of the interview for eligible participants:
Date of interview
Site of interview
Lead Interviewer name
Secondary Interviewer name
Participant provided consent (circle one)

Yes

(Observed) Gender
(Ask participant) Hispanic/Latino Ethnicity

Male
Yes

(Ask participant) Race

White

Female
No
Other (circle one): American Indian/Alaska
Native, Asian, Black/African American,
Native Hawaiian/Other Pacific Islander

Participant ID

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Interviewer Post-Interview Comments:
Complete the following based on the screener and interview responses[to be used to track diversity in sample
and for subsequent recruitment]
Age:
☐ 18-29
☐30-39
☐ 40-49
☐ 50 or older
Gender:
☐ Male
☐Female
Preferred drug of choice:
_______________________
Reported sex work?
☐ Yes
☐No
Enrolled in NEP?
☐ Yes
☐No
HIV
☐ Pos
☐Neg
☐ Not tested
☐ Tested, don’t know ☐ Refused to disclose
Hepatitis C
☐ Pos
☐Neg
☐ Not tested
☐ Tested, don’t know ☐ Refused to disclose

Other Post-Interview Comments and Observations:

HIV in SE Indiana Exploratory Study

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INTERVIEW GUIDE – MAKE SURE RECORDER IS ON
OK, today is [insert date]. My name is [insert date] and my assistant is [insert date]. We are with
interviewee number [say number].
For the Record, we just want to confirm that you understand information in the study information
sheet provided, and that you agree to participate in the interview.
Ok, great, let’s get started.

HIV IN THE COMMUNITY MONTH – INTERVIEWEE PERSPECTIVE
Many of our questions will ask you to share your experiences CURRENTLY regarding injection
drug use. But we will also ask about your experiences BEFORE you were aware of HIV in
[County Name] County.
When did you become aware of HIV in [County Name] County? What month was that?
Write month: _______________________
Ok, think of that month when we ask you about experiences before you learned of HIV in the
community.
Great, let’s get started with our first question.
Note to Interviewer: You may need to slightly adjust question and probes to account for variations
in using experiences [e.g., substitute different names of drugs; adjust between different forms drugs
– pills versus powder]; right now the interview guide is written with Opana as the reference drug.

A. Drugs Used, Drugs of Choice
Ok, let’s start by talking about the drugs you use.

QA1. What drugs do you CURRENTLY use?
Probes
- If prescription drugs, are they used how the doctor told you to use them?
- Any used daily? On and off? Together with other drugs?
- What drugs do you use the most?
- When used and how much?
- How do you use them? Swallow? Snort? Smoke? Inject?
- How often do you usually inject? – daily, weekly, monthly?

QA2. How has your drug use changed, if at all, since you became aware of the HIV in the
community and why [i.e., since – insert month].

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B. Last Experience Injecting Opana [ADJUST DRUG IF OPANA IS NOT REGULARLY INJECTED
BUT A DIFFERENT DRUG IS]
QB1. Now I would like to know more about your experiences using Opana.
Let’s begin by talking about the LAST time you injected Opana.
When was that – day, time, year? _______________
Ok, describe to me your experiences the last time you injected? Walk me through the process – where,
when, with who, how?
[Note to interviewer: Let interviewee describe the episode. Listen for answers to each of the following
questions below. Once interviewee’s story is told, probe for any questions not answered. Be sure to
remind the person to NOT give names when asking who questions; can use pronouns such as myself, or
roles such as my friend].
NOTE TO INTERVIEWER: BRING A BOTTLE OF WATER, A FEW PENS, A SODA CAN BOTTOM, A FILTER, ETC
AND ASK THEM TO ACTUALLY ILLUSTRATE WHAT HAPPENS
Probes - Content Areas for Drug Injection Narrative:
-

Before Using:
o What was going on that day?

Buying/Exchanging/Stealing/Being Prescribed
o How did you get the drugs?
o How much drugs? For whom – just you? To be shared?
o Who got them (no names, relationship only)? Who paid? Who was there?
o How did you get money for the drugs? Any pooling of money together? If didn’t have
money, how did you get your portion?

Time, Place and People
o What time of the day?
o Where? At home? On the street, car, public place? (Try to get a sense of living situation)
o Nature of place – is it ‘safe’ from police?
o How many people were there? What are your relationships with these people?

Nature/Source of Syringe and Injection equipment
o Describe the syringe you used- what kind was it? Fixed/ vs removable needle?
o New? Used? Used by whom? How often prior used?
o Where did you get the needle and other injection equipment [filter, cooker, etc.] and
how?

Preparing
o Who prepared the drugs?
o How were they prepared? [step by step from pill form to ready to use form]

HIV in SE Indiana Exploratory Study
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Version: 08/27/2015

If sharing drugs with others, how were they measured and divided? [pills cut before
hand]? Using ONE syringe to divide up drugs into other syringes? [front or back
loading]?
What about rinsing syringes? Any rinsed? Rinsed with what? With whom? Any not
rinsed with certain folks?

Injecting
o How was the drug injected (self? another person?)
o How were needles shared, if at all? Who shared with? Relationship with those you
shared with? Who went first (second, third, etc.) and why?
o How about other injection equipment? Anything else shared such as water, cookers,
filters, etc.? Can you tell me more about that?
§ Probe for each individually – start with cookers, then filters, then water
§ Probe for whether these sources vary by whom they may share with [e.g.,
partner versus other]

Number of times injected per day
o During the last day you injected, can you tell me about the number of times you
injected, how often, when, with whom, etc.?

HIV/HCV
o Was HIV or HCV discussed with anyone who was with you that last time? Did they bring
it up with you? Or was anyone’s Hep C or HIV status already known to you or others?
Was Your HIV/Hep C status known? Sharing partner’s status? Others who were there
whom you did not share with? If so, how and when?
o How did knowing or not knowing your own or others’ status in the room affect injecting
drugs that time?
o Did you or anyone else do anything specifically to make it less likely for someone who is
HIV or Hep C positive to be passed to someone who is negative? What did you or
someone else do? If affected by doing things to reduce risk, probe what kinds of things,
if any, to reduce risk were done?

C. Typical Current Experiences Injecting Opana [ADJUST DRUG IF NEEDED]
QC1. How, in any way, was the LAST time you injected different from your usual experience
injecting in the past few weeks? Is what you described above your usual experience NOW? If not
usual, can you tell me about what is different?

D. Experiences Injecting Opana before HIV in the Community
QD1. Ok, now I want to shift to your experiences BEFORE you were aware of HIV in [County
Name] County [remind them of the month reported earlier]? How is your usual experience
injecting Opana NOW similar to or different from your usual experience THEN? How so?
Probes – especially for these content areas from the above narrative:
- Before Using
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-

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Buying/Exchanging/Stealing/Being Prescribed
Time, place and people
Nature of Syringe
Preparing
Injecting
HIV/HCV
Number of times injected per day

E. Experiences Injecting other Drugs
QE1. Tell me how you prepare and inject any other drugs, such as heroin, differently from
how you prepare and inject Opana? Please explain the differences and similarities?
Probes
- Any differences over time? That is, BEFORE you were aware of HIV in the community as
compared to NOW?

F. Transition from Non-Injection to Injection Drug Use
QF1. Ok, tell me about your experiences of how you first started injecting drugs; why did you
start injecting, how old were you, where were you?

Note to interviewer: Try to construct a timeline and circumstances around the transition from noninjection drug use to first injection
Probes
-

What drugs did you use before you started injecting?
Why did you start injecting?
How old were you?
What drug injected when first time injecting?
When was the first time using Opana? Have you ever injected any other painkillers? What are
they? [how old? month, year?] First time injecting [how old? month, year?] Where you got the
drug? Have you ever been prescribed Opana by a Doctor? How did you initially start using
Opana? What made you use it differently?
Describe how using Opana increased over time; explore if used different types of prescription
opioids over time/other substances as well as order of use.
Explore preparing and injection practices to see if risk started immediately upon first injection.
Have you changed how you inject Opana from the first time you used to now? How?

G. Experiences With Needle Exchange Program
QG1. Tell me about your experiences using the needle exchange program? Do you use the
program?
Probes for “folks who have used”
- Probe about context and content of program (If any are problematic, ask why and what could be
done better to meet their needs):
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HIV in SE Indiana Exploratory Study
o
o
o
o
o
o
o
o
o
o
o
o
-

Version: 08/27/2015

How are the services working for you? Are you getting what you need?
Use of NEW CENTER versus the SUV
Location of new center
Location of the SUV
Type of needles and amount of needles given out
Type of filters provided [probe about cotton, whether they think cig filters are safe; size]
Time it takes to get the needles
Hours of operation of the SUV? Or the NEP
People providing the needles
Police presence
Community perceptions
Stigma and discrimination

Do you give or sell needles to anyone? If yes, can you tell me about that? How does this affect
your needle supply, if at all?

Probes if “Never used”:
- Why not? What are some reasons? Prompts - Anything to do with?
o location
o hours of operation
o police presence
o community perceptions
-

What would need to change for you to attend the needle exchange program?

Probe for all
BRING A TYPICAL BAG THAT IS GIVEN AT THE NEP WHEN THEY FIRST ENROLL AND ASK THEM TO TELL
YOU ABOUT THE ITEMS – WHATS USFUL, WHATS NOT?
Note To Interviewer: Do A Time Check, And ONLY Ask The Sex Questions If You Think You Can Get
Through Everything. If Not, Skip to I, OR JUST ASK QH3, And Go To I.

H. Sexual Risk Behaviors
Now I would like to ask some questions about sex. We realize that this is a very personal subject, but
your answers are very important to understanding what people may need here. Your answers will
remain completely private and remember names will not be attached to anything you say to us.

QH1. I would like to talk about the last time you had sex with someone that included vaginal
or anal sex WITHOUT a condom. Note: This includes if a condom broke or came off during sex.
When was that? [if always use condoms, skip to QH2].
Date [month/year]_________________

Ok, think back now and try to remember as much as you can about that time, and tell me.
What is your relationship with this person? What you were doing? Why did you have sex

HIV in SE Indiana Exploratory Study

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with them? Were others there in the house? Other having sex together? How did injecting drugs fit in,

if at all?

[Interviewer note: Let interviewee describe the episode. Listen for answers to each of the following
questions below. Once interviewee’s story is told, probe for any questions not answered. Be sure to
remind the person to NOT give names when asking who questions; can use pronouns such as myself, or
roles such as my boyfriend]. Only select areas are covered here for sake of time]
Probes Select Content Areas for Sexual Interactions:
- Partner characteristics (age, gender)
o Relationship with this partner (duration and nature of relationship, where/when/how
met partner; main, casual, paying or exchange)
o Have you ever had sex with them previously? How often? Past sexual experiences with
this partner, whether condoms used.
o Did you want to have sex with this person? Can you tell me more about that?
-

Sexual Events/Condom Use
o What determined the kinds of sex you had? [foreplay/touching, plating; Intercourse;
oral or whatever]
o Do you typically have sex with this person?
o Why did you decide to NOT use a condom?/why didn’t you use condoms?

Using Drugs
o Did you and/or your partner use before/during/after sex? Did you and/or your partner
use alcohol before/during, after sex? Drugs or alcohol used by you or this sex partner
before, during or after having sex (Injected drugs/non-injected drugs/alcohol; levels of
intoxication).

HIV
o
o
o

Have you ever talked about HIV with your sex partner(s)? (Your status? Partner’s status?
If so, how? Before or after sex?)
If not discussed, then what did you believe (or assume)? Before or after sex?
How did knowing or not knowing your partner’s HIV status affect having sex this time.

QH2. Thinking about when you have sex in general, have you ever used a condom with sex?
Probes:

What makes it easier to use condoms/protection with partners?
What are some of the reasons you haven’t used condoms/protection?

QH3. Have you ever had sex with someone and they gave you something for it? Have they
ever given you money? How about drugs? What about something else like food or a place to
sleep?

Probes:
- How often? With whom? Where do the folks [clients] come from?
- What about condoms? Used, not used? Why?
- Can you tell me more about that both before and after you learned about HIV in [County Name]
County?

HIV in SE Indiana Exploratory Study

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I. HIV Testing and Care & Treatment Experiences
Now I have some questions about HIV testing.

QI.1. Have you ever been tested for HIV before- why or why not? Tell me about your
experiences of being tested for HIV? Test? No Test?
Probes if “Never tested”
- Why not? What has kept you from getting tested?
- What would make it more likely or easier for you to get tested?
Probes if “Tested”
- How many times? Where? When [before/after you knew about HIV in the community]?
- When were you last tested (month and year)?
- How, if at all, did that testing change how you inject drugs or prepare them to be used?
- Have you changed how you use condoms when having sex? Change? No change? How so?
- How about use of the needle exchange program? Did it affect your use of the program?
Increase? Decrease? How so?
- Did you get your HIV test results? If not, why not? If yes, what were they?
If you don’t feel comfortable telling me, you don’t have to.
IF PARTICIPANT IS HIV POSITIVE

QI2. Tell me what that has been like for you to be diagnosed positive? How has your life
changed? What have your experiences with HIV doctors been like? Taking HIV meds?

Probes:
- If not in care, why not? What would it take to get you into care? What would make you want to
be in care?
IF PARTICIPANT IS HIV NEGATIVE
QI3. I would like to ask you about some HIV prevention services that may be available to you. Have
you been told how often you should be retesting for HIV? [interviewer should also be aware of PreP
and TasP when probing here as those are effective prevention measures as well]?
Probes:
- If they seem to have accurate knowledge but are not retesting, ask why? What would make it
more likely for you to get tested again for HIV?

QI4. Have you heard about any medications that prevent HIV? Can you tell me what you
have heard?
Probes:
- Who told you about taking HIV meds to prevent HIV infection?
- Would you be interested in taking it? Why not? What are your concerns? What would make you
want to take the pill?

QI4a. Is there anything you have heard about people who are HIV positive taking medications
that can prevention transmission to others? Can you tell me what you have heard?
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QI.5. Many folks who inject drugs in [insert city name] have tested positive for HIV but others
have not tested positive. Why do you think some people tested HIV+ and others have not?
What keeps some people negative?
J. Hepatitis C Testing and Care & Treatment Experiences
J.1. What about your experiences being tested for Hepatitis C? Tell me about your
experiences. Test? No Test?
Probes if “Never tested”:
- Why not? What would it take to get you tested? What would make it easier for people to test for
Hep C?
Probes if “Tested”:
- What were the results? What happened afterwards?
- If positive: Can you tell me what that has been like for you? How has your life changed? What have
your experiences with HCV care providers been like?
- If not in care, why not? What would it take for you to get care? What would make it easier to get
into care?

K. FINAL QUESTION
We trying to understand the risk for HIV and other health problems in your community and how to help
prevent disease. What else do you think is important for me to know that I haven’t already asked
about? Is there anything else you would like to share?

WRAP UP AND REFER
-

THANK THEM
PROVIDE RESOURCE BAG AND REFER IF NEEDED

Study ID #: _Rÿÿÿ

Invasive GAS in LTCF 2015
Employee Survey
Form Approved; OMB No. 0920-1011; Exp Date: 03/31/2017

Date Completed: ____/____/____
A. Employee Background
3. Sex:

ÿ Male

2. Age:

1. Name:

ÿ Female

4. Employed at Capital Care since: ______/______/______

5. List occupation: ÿ Activity aid

ÿ Administrative

ÿ CNA

ÿ Dietary

ÿ Food service

ÿ Housekeeping

ÿ Laundry

ÿ PT/OT

ÿ Pharmacist

ÿ Physician

ÿ Maintenance

ÿ RNA

ÿ RN/LPN

ÿ Social service ÿ Van driver

ÿ Other __________________________
ÿ Yes ÿ No (If no, skip to Section B)

6. Since May 3, 2015, did you work in any other patient-care facility?
Name & city of facility

Dates of employment

Have you been in contact with a
patient infected with group A strep?

What was the patient’s diagnosis?

Start:
____ / _____ / _______
End:
____ / _____ / _______

ÿ Yes

ÿ Strep throat

ÿ Impetigo

ÿ No
If yes, date of contact:
____ / _____ / _______

ÿ Cellulitis

ÿ Bacteremia/Sepsis

Start:
____ / _____ / _______
End:
____ / _____ / _______
Start:
____ / _____ / _______
End:
____ / _____ / _______

B. Job Description at Capital Care
8. Areas usually worked:

ÿ Patient rooms

9. Shifts usually worked:

ÿ Day

ÿ Other, specify: ________________

ÿ Yes

ÿ Strep throat

ÿ Impetigo

ÿ No

ÿ Cellulitis

ÿ Bacteremia/Sepsis

If yes, date of contact:
____ / _____ / _______

ÿ Other, specify: ________________

ÿ Yes

ÿ Strep throat

ÿ Impetigo

ÿ No
If yes, date of contact:
____ / _____ / _______

ÿ Cellulitis

ÿ Bacteremia/Sepsis

ÿ Other, specify: ________________

7. As part of your job, do you have physical contact with patients?

ÿ Nurses’ station

ÿ Evening

ÿ Night

ÿ Cafeteria

ÿ Yes

ÿ No
(If no, skip to Section D)

ÿ Other _____________________

ÿ Other________________________

10. Patient units usually worked: ÿ 1E ÿ 1W ÿ 2E ÿ 2W ÿ 3E ÿ 3W ÿ 4E ÿ 4W ÿ Do not work in patient units ÿ All patient units
11. Which days do you usually work (circle ALL that apply):
Sunday

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

12. What kind of patient contact do you have? (check ALL that apply)

ÿ Give oral medications

ÿ Feeding resident

ÿ Change dressings/wound care

ÿ Gastrostomy care ÿ Handle urinary catheter

ÿ Respiratory therapy

ÿ Bathe resident

ÿ Assist with patient transfer

ÿ Clean room

ÿ Handle soiled diapers/bedpans

ÿ Deliver meal trays

ÿ Take vital signs

ÿ Handle soiled linens/bedding

ÿ Tracheostomy care

(OVER)

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)
1 of 2

C. Work Practice

13. Do you use soap and water to clean your hands?

ÿ Yes

ÿ No

14. Do you use alcohol-based hand sanitizer to clean your hands?

ÿ Yes

ÿ No

15. Please answer the following questions

(circle answer)

Always

Do you perform hand hygiene BEFORE physical contact with patients?

N/A

Do you perform hand hygiene BEFORE physical contact with each patient’s
environment or belongings (e.g. bedside table, refrigerator, rolling walker, etc.)?

N/A

Do you perform hand hygiene AFTER physical contact with patients?

N/A

Do you perform hand hygiene AFTER physical contact with each patient’s environment
or belongings (e.g. bedside table, refrigerator, rolling walker, etc.)?

N/A

Do you perform hand hygiene BETWEEN contact with patients?

N/A

Do you use the sink or alcohol-based sanitizer in the patient’s bathroom?

N/A

Do you use the sink or alcohol-based sanitizer at the nurse’s station?

N/A

Do you use gloves when changing bandages/dressing wounds?
i. If yes, do you change gloves between patients/patient rooms?
j. If yes, do you perform hand hygiene before donning gloves?
k. If yes, do you perform hand hygiene after removing gloves?

1
1
1
1

2
2
2
2

3
3
3
3

4
4
4
4

5
5
5
5

N/A
N/A
N/A
N/A

Do you use gloves when cleaning soiled patients or linens?
m. If yes, do you change gloves between patients/patient rooms?
n. If yes, do you perform hand hygiene before donning gloves?
o. If yes, do you perform hand hygiene after removing gloves?

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1
1

2
2
2
2

3
3
3
3

4
4
4
4

5
5
5
5

N/A
N/A
N/A
N/A

Do you use person protective equipment (PPE) when bathing patients?
1
2
3
4
5
q. If yes, please specify type of PPE: ________________________________________________________________

D. Your Health
18. a.
b.

16. Do you have paid “Sick Leave”?

ÿ Yes

ÿ No

ÿ Yes

Since May 3, 2015, have you had a sore throat?
When? ______ / _______ / _______

ÿ No

(If no, skip to #19)

c.
e.

Was a throat swab for testing collected from you?
ÿ Yes
ÿ No d. If yes, specify month: _________________
Was a rapid strep throat test done (you would have been given results immediately)?
f. If yes, specify month: _________________
g. If yes, was the result positive?

Were you diagnosed with strep throat?

ÿ Yes

ÿ No

i. If yes, specify month: _________________

j.
l.

Did you miss work for this illness?
How many days were you ill? _____________

ÿ Yes

ÿ No

k. How many days did you miss? ____________

ÿ Yes

ÿ No

n. If yes, antibiotic name ___________________

a. Since May 3, 2015, did you have a rash, open wound, or skin infection? ÿ Yes ÿ No (If no, skip to #20)
b. When? ______ / _______ / _______ c. What was your diagnosis? ____________________________
d. Did you miss work for this illness?
f. How many days were you ill? _____________

ÿ Yes

ÿ No

How many days did you miss? ____________

g. Did you receive antibiotics for this condition?

ÿ Yes

ÿ No

If yes, antibiotic name __________________

20. If you’re feeling sick before a work shift, how do you notify Capital Care? ___________________________________________
21.

N/A

17. Did you receive prophylaxis for group A streptococcal infection? ÿ Yes ÿ No When? ___ / ___ / ___

m. Did you receive antibiotics for this condition?
19.

Never

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. Since May 3, 2015, did anyone in your household have a sore throat?
ÿ Yes ÿ No
d. When? ______ / _______ / _______
e. Who (relationship)? ______________________

ÿ Yes

e. Was he/she diagnosed with strep throat?
g. Were they treated? ÿ Yes

ÿ No

ÿ No If so, with what? ________________________________

h. During the past 3 months, did anyone in your household have impetigo or cellulitis (skin infections)?
i. When? ______ / _______ / _______
END – Thank you!

ÿ Yes

ÿ No

Study ID #: _Rÿÿÿ

Investigation of GAS outbreak in LTCF, Illinois – 2015
Resident Record Extraction Form
Form Approved; OMB No. 0920-1011; Exp Date: 03/31/2017

Person Completing Form ______________________

Date Completed: ____/____/____

If CONTROL, date of matched case’s culture: ____/____/____
A. GAS Lab results
1. Did resident have any cultures/tests positive for GAS?

ÿ Yes
#

ÿ No

Date obtained

Site cultured

a.
____/_____/_______
b.
____/_____/_______
c.
____/_____/_______
d.
____/_____/_______
e.
____/_____/_______
f.
____/_____/_______

ÿ Blood
ÿ Sputum
ÿ Blood
ÿ Sputum
ÿ Blood
ÿ Sputum
ÿ Blood
ÿ Sputum
ÿ Blood
ÿ Sputum
ÿ Blood
ÿ Sputum

ÿ Pleural
ÿ Pleural
ÿ Pleural
ÿ Pleural
ÿ Pleural
ÿ Pleural

ÿ Skin/Wound: _____________
ÿ Other __________________
ÿ Skin/Wound: _____________
ÿ Other __________________
ÿ Skin/Wound: _____________
ÿ Other __________________
ÿ Skin/Wound: _____________
ÿ Other __________________
ÿ Skin/Wound: _____________
ÿ Other __________________
ÿ Skin/Wound: _____________
ÿ Other __________________

ÿ Rapid strep
ÿ Throat
ÿ Rapid strep
ÿ Throat
ÿ Rapid strep
ÿ Throat
ÿ Rapid strep
ÿ Throat
ÿ Rapid strep
ÿ Throat
ÿ Rapid strep
ÿ Throat

B. Resident Background
2. Sex:

ÿ Male

ÿ Female

3. Age: __________

4. Date of Birth: ____/____/____

5. Room history for 1 month prior to GAS for case or time of time match for control:
Room #

Dates

Type

Roommate
(Dates)

___/___/____ to ___/___/____

ÿ Private

ÿ Double

ÿ Triple

___/___/____ to ___/___/____

ÿ Private

ÿ Double

ÿ Triple

___/___/____ to ___/___/____

ÿ Private

ÿ Double

ÿ Triple

___/___/____ to ___/___/____

ÿ Private

ÿ Double

ÿ Triple

___/___/____ to ___/___/____

ÿ Private

ÿ Double

ÿ Triple

___/___/____ to ___/___/____

ÿ Private

ÿ Double

ÿ Triple

___/___/____ to ___/___/____

1 of 4
Public reporting burden of this collection of information is estimated to average 45 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)

Study ID #: _Rÿÿÿ

Investigation of GAS outbreak in LTCF, Illinois – 2015
Resident Record Extraction Form
6. Total length of stay at CC (most recent stay only) at time of group A streptococcal culture (mark only one):
ÿ ≤ 1 week

7a. Is resident deceased?

ÿ 1-3 weeks

ÿ 4-8 weeks

ÿ ≥ 8 weeks

ÿ Yes

If yes, date of death:

____/____/____

ÿ No

b. If resident died, death was:

8. Resident’s physicians?
Physician’s name

ÿ Related to GAS infection

ÿ Possibly related to GAS infection

ÿ Not related

ÿ Not applicable

Name of practice

Specialty (e.g., wound care, etc.)

a.
b.
c.
d.

9. List last admission prior to GAS infection or time of match for controls (including home, CC, hospitals, and any
other LTCF).
Name & Location

Admission Date

Discharge Date

______ / _______ / _______

Diagnosis (if

Admission

applicable)

from

C. Medical History
10. Which medical condition(s) does the resident have? (mark ALL that apply):
ÿ Diabetes

ÿ CHF/history of MI

ÿ Peripheral Vascular Disease ÿ Stroke

ÿ Asthma/COPD

ÿ Hypertension

ÿ Chronic Leg Edema

ÿ Recent Herpes Zoster

ÿ Dialysis

ÿ Renal insufficiency

ÿ Dementia

Chronic skin condition

ÿ Cancer, specify type: _________________

ÿ Immunosuppressed/immunosuppression

ÿ None

ÿ Other: _____________________________________
(Note: immunosuppression includes: HIV/AIDS, chemo, radiation, immunosuppressive meds, including
tacrolimus [Prograf], sirolimus [Rapamune], mycophenolate mofetil [Cellcept], high-dose or chronic steroids
[prednisone, methylprednisone, hydrocortisone, dexamethasone] methotrexate.)
11. Weight: ____________ lbs or kg (circle unit of measure)

12b. Height: __________

12. Did patient have any surgical wounds, pressure ulcers, or other wounds at the time of admission to CC?
ÿ Yes

If yes, how many _____

ÿ No

2 of 4

Study ID #: _Rÿÿÿ

Investigation of GAS outbreak in LTCF, Illinois – 2015
Resident Record Extraction Form
13. Did patient have any surgical wounds, pressure ulcers, or other wounds at the time of first GAS isolation for
case or at time-match for controls?
ÿ Yes

ÿ No

If yes, how many _____

14. Did the patient receive wound care consulting services within 1 month prior to the GAS case or time-match for
controls?
ÿ Yes

ÿ No

Dates

Name(s) of doctors or nurses

15. Did the patient receive wound care WITHOUT wound care consultation within 1 month prior to GAS case or
time-match for controls?
ÿ Yes

ÿ No

16. Has the patient had a surgical procedure within 1 month of GAS infection or time match for control?
ÿ Yes

ÿ No
Procedure

Date

Incision Site

______ / _______ / _______
______ / _______ / _______

17. Type of IV access present at time of positive GAS culture/referral from CC?
15a. Access Type

15b. Date of Insertion

ÿ None

ÿ Not applicable

15c. Person Inserting (e.g. RN)

18. At time of GAS case or time-match for control, was a clinical diagnosis made of:
ÿ Yes
ÿ No
Date of Onset ___/___/____
a. cellulitis
b. wound infection
c.

pharyngitis

d. bacteremia

ÿ Yes
ÿ Yes
ÿ Yes

ÿ No
ÿ No
ÿ No

3 of 4

Date of Onset ___/___/____
Date of Onset ___/___/____
Date of Onset ___/___/____

Study ID #: _Rÿÿÿ

Investigation of GAS outbreak in LTCF, Illinois – 2015
Resident Record Extraction Form
19. Within 1 month of GAS or time-match for control, did the resident have any of the following signs or symptoms?
(mark ALL that apply)
Date of onset (dd/mm/yy)
a.

ÿ Fever (≥100.5oF or 38oC)

______ / _______ / _______

ÿ Sore throat

______ / _______ / _______

ÿ Purulent discharge from wound

______ / _______ / _______

Site:

ÿ Wound – warm on touch

______ / _______ / _______

Site:

ÿ Wound – redness

______ / _______ / _______

Site:

ÿ Edema at the site

______ / _______ / _______

Site:

ÿ Increased pain at the site

______ / _______ / _______

Site:

C. Resident Baseline Status

Max temp recorded:

(Can get further information from nursing)

20. Which appliances does the resident use (mark ALL that apply):
ÿ Tracheostomy

ÿ Nasal cannula

ÿ Oxygen mask

ÿ Chronic Foley

ÿ G or J tube

ÿ Nasogastric tube

ÿ Colostomy/ileostomy

ÿ Temporary Foley

ÿ Dialysis catheter

ÿ PICC line

ÿ Other, specify: ____________________________

21. Describe the resident’s ambulatory status: (mark ALL that apply)
ÿ Walks independently

ÿ Walks with support

ÿ Wheelchair

ÿ Geri chair

ÿ Bed bound

22. Indicate if resident incontinent of: (mark ALL that apply)
ÿ Stool

ÿ Urine

ÿ Not Incontinent

23. Is the resident being tube fed?

ÿ Yes

ÿ Urinary catheter

ÿ Colostomy/Ileostomy

ÿ Unknown

ÿ No

24. Did the resident participate in the following activities in the 1 month prior to diagnosis or time-match for controls
(mark ALL that apply):
a.

ÿ PT/OT

Times per 2 month period: ______

ÿ Speech pathology

Times per 2 month period: ______

ÿ Podiatry

Times per 2 month period: ______

ÿ Other: ____________________

Times per 2 month period: ______

4 of 4

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

Legionella Environmental Assessment Form

Public reporting burden of this collection of information is estimated to average 120 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)

Centers for Disease Control and Prevention

Legionella Environmental Assessment Form
HOW TO USE THIS FORM
This form enables public health officials to gain a thorough understanding of a facility’s water systems and assist facility
management with minimizing the risk of legionellosis. It can be used along with epidemiologic information to determine whether
to conduct Legionella environmental sampling and to develop a sampling plan. The assessment should be performed on-site by an
epidemiologist and an environmental health specialist with knowledge of the ecology of Legionella. Keep in mind that conditions
promoting Legionella amplification include water stagnation, warm temperatures (77-108°F or 25-42°C), availability of organic
matter, and lack of residual disinfectant such as chlorine. For training and information, please visit CDC’s legionellosis resources
webpage at: http://www.cdc.gov/legionella/outbreak-toolkit/.
Complete the form in as much detail as possible. Do not leave sections blank; if a question does not apply, write “N/A”. If a
question applies but cannot be answered, explain why. Where applicable, specify the units of measurement being used (e.g., ppm).
Completion of the form may take several hours.

BEFORE ARRIVING ON SITE
❒❒ Request the attendance of the lead facility manager as well as others who have a detailed knowledge of the
facility’s water systems, such as a facility engineer or industrial hygienist.
❒❒ Request that they have maintenance logs and blueprints available for the meeting.
❒❒ Bring a plastic bottle, thermometer, pH test kit, and a chlorine test kit that can detect a wide range of residual
disinfectant (<1 ppm for potable water and up to 10 ppm for whirlpool spas).
❒❒ If the epidemiologic information available suggests a particular source (e.g., whirlpool spa, cooling tower),
request that they shut it down (but do not drain or disinfect) in order to stop transmission.

INSTRUCTIONS FOR MEASURING WATER PARAMETERS IN THE PREMISE PLUMBING
(TABLE P. 8)

It is very important to measure and document the current physical and chemical characteristics of the potable water, as this
can help determine whether conditions are likely to support Legionella amplification.
STEP 1: Plan a sampling strategy that incorporates all central hot water heaters/boilers and various points along each loop
of the potable water system. For example, if the facility has one loop serving all occupant rooms, an occupant room near
(proximal) the central hot water heater and another at the farthest point (distal) of the loop should be sampled.
STEP 2: For each sampling point (e.g., tap in an occupant room):
a. Turn on the hot water tap. Collect the first 50 ml from the tap. Measure the free chlorine residual and pH. Document
the findings in the table on p. 8. Note: If there is no residual chlorine in the hot water, measure it in the cold water.
Note: Total chlorine should be measured instead of free chlorine if the method of disinfection is not chlorine (e.g.,
monochloramine).
b. Allow the hot water tap to run until it is as hot as it will get. Collect 50 ml and measure the temperature. Document the
temperature and the time it took to reach the maximum temperature.

National Center for Immunization and Respiratory Diseases
Division of Bacterial Diseases
06/2015

CS254961-A

LEGIONELLA ENVIRONMENTAL ASSESSMENT FORM
Persons completing the assessment:
Name: _______________________________ Job Title: __________________ Organization:_________________
Telephone: ___________________________ E-mail: ___________________
Name: _______________________________ Job Title:___________________ Organization:_________________
Telephone: _
E-mail:
Assessment details:
Facility Name: _____________________________________________ Date of Assessment: __________________
Facility Address: ______________________________________________________________________________

street

city

state zip

Person(s) interviewed during assessment:
Name: _______________________________ Job Title: __________________
Name: _______________________________ Job Title: __________________
Name: _______________________________ Job Title: __________________
Facility Characteristics
1. Is this a healthcare facility or senior living facility with skilled nursing care (e.g., hospital, long term care/rehab/assisted living/
skilled nursing facility, or clinic)?
❑ YES ➔ If yes, skip to Q.3 & also complete Appendix A.
❑ NO
2. If NO, indicate type of facility (check all that apply):
❒ Senior living facility (e.g., retirement home without skilled nursing care)
❒ Other residential building (e.g., apartment, condominium)
❒ Hotel, motel, or resort
❒ Recreational facility (e.g., health club, water park)
❒ Office building
❒ Manufacturing facility
❒ Restaurant
❒ Other ___________________________________________________
3. Total number of buildings on campus: __________ Total number of buildings being assessed: __________
4. Total number of rooms that can be occupied overnight (e.g., patient rooms, hotel rooms): _________
5. Does occupancy vary throughout the year?

❑ YES

❑ NO

If YES, seasons with lowest occupancy (check all that apply):
❑ Winter ❑ Spring ❑ Summer ❑ Fall
6. Are any occupant rooms taken out of service during specific parts of the year, e.g., low season?
❑ YES ❑ NO
If YES, which rooms? ______________________________________________________
2 | CDC Legionella Environmental Assessment Form | www.cdc.gov/legionella/outbreak-toolkit/

7. Average length of stay for occupants (check one):
❑ 1 night ❑ 2-3 nights ❑ 4-7 nights ❑ >7 nights
8. Does the facility have emergency water systems (e.g., fire sprinklers, safety showers, eye wash stations)?
❑ YES ❑ NO
If YES, are these systems regularly tested (i.e., sprinkler head flow tests)? ❑ YES ❑ NO
If YES, how often and when was the last test? __________________________________________________
9. Are there any cooling towers or evaporative condensers on the facility premises?
❑ YES ➔ If yes, also complete Appendix B.
❑ NO
10. Are there any whirlpool spas, hot tubs, or hydrotherapy spas on the facility premises?
❑ YES ➔ If yes, also complete Appendix C.
❑ NO
11. Are there any decorative fountains, misters, water features, etc. on the facility premises?
❑ YES ➔ If yes, also complete Section D.
❑ NO
12. Does the facility have centralized humidification (e.g., on air-handling units) or any room humidifiers?
❑ YES ❑ NO
If YES, describe their location and operation:_

13. Has there been any recent (last 6 months) or ongoing major construction on or around the facility premises?
❑ YES ➔ If yes, also complete Appendix E.
❑ NO
14. Has this facility been associated with a previous legionellosis cluster or outbreak?
❑ YES ❑ NO
If YES, please describe number of cases, dates, source if found, and any interventions (immediate and long-term) to prevent
recurrence: _

15. Does the facility have a water safety plan or Legionella prevention program?
❑ YES ❑ NO
If YES, does the facility ever test for Legionella in water samples?
❑ YES ➔ If yes, obtain copies of results ❑ NO
If YES, please describe the plan briefly here (does it include clinical disease surveillance and/or environmental Legionella
surveillance?) and obtain a written copy of the program policy:
_

3 | CDC Legionella Environmental Assessment Form | www.cdc.gov/legionella/outbreak-toolkit/

4 | CDC Legionella Environmental Assessment Form | www.cdc.gov/legionella/outbreak-toolkit/

16. Describe each building that shares water or air systems, including the main facility

Original
Construction

Later Construction
(renovation,
expansion)

Stories or
Levels

Occupancy rate
(%)*

Daily Census
(yr. avg.)

Use
(List all types of uses)
e.g., occupant rooms, utilities,
heating/AC plant

Building Name
(List main facility building first)
Year Completed

From/To or “N/A”

*[occupancy rate = (# of rooms occupied overnight / total # of rooms) X 100]

Rate (%) or “N/A”

#/day or “N/A”

For healthcare, specify:
Outpatient = O
Inpatient (acute) = I
Chronic = C
Intensive care = ICU
Transplant = Tx

Water Supply Source
17. What is the source of the water used by the facility? (Check all that apply)
❑ M
unicipal water if YES:
Name of supplier ___________________________________________________
How is the municipal water disinfected? (Check one) ❑ Chlorine ❑ Monochloramine ❑ Other ________
Has treatment of municipal water changed in the past year? ❑ YES ❑ NO
If YES, specify _________________________________________________________________________
❑ Non-municipal well if YES:
How is the well water disinfected? (Check one) ❑ Chlorine ❑ Other ___________ ❑ Not disinfected
Is the water filtered onsite? ❑ YES ❑ NO
❑ Other _________________________________________________________________________________
18. Have there been any pressure drops, boil water advisories, or water disruptions (e.g., water main break) to the facility in the
past 6 months? ❑ YES ❑ NO
If YES, describe what happened and which buildings or parts of buildings were affected: ______________________
________________________________________________________________________________________
________________________________________________________________________________________
19. Does the facility monitor incoming water parameters (e.g., residual disinfectant, temperature, pH)?
❑ YES ➔ If yes, obtain copies of the logs ❑ NO
If YES, what is the range of disinfectant residual, temperature, and pH entering the facility? ____________________
________________________________________________________________________________________
Premise Plumbing System
Note: It is important to gain an understanding of where and how water flows, starting where it enters the
facility and including its distribution to and through buildings to the points of use. Understand water processes,
including but not limited to: heating, storage, filtration, UV irradiation, and addition of secondary disinfectants.
Refer to a facility map and blueprints; obtain copies of these and/or draw a diagram and include with the
completed assessment.
20. Are cisterns and/or water storage holding tanks used to store potable water before it’s heated?
❑ YES ❑ NO
21. Is there a recirculation system (a system in which water flows continuously through the piping to ensure constant hot water to
all endpoints) for the hot water?
❑ YES ❑ NO
If YES, please describe where it runs and delivery/return temperatures if they are measured: ___________________
________________________________________________________________________________________
________________________________________________________________________________________
22. Are thermostatic mixing valves used?
❑ YES ❑ NO
If YES, describe where they are located (ideally, mixing valves are close to the point of use): _____________________
________________________________________________________________________________________
________________________________________________________________________________________

5 | CDC Legionella Environmental Assessment Form | www.cdc.gov/legionella/outbreak-toolkit/

6 | CDC Legionella Environmental Assessment Form | www.cdc.gov/legionella/outbreak-toolkit/

23. How is the hot water system configured to deliver hot water to each building?
Type of system
Building name

(e.g., instantaneous
heater, hot water heater
with a storage tank,
solar heating)

Name of system
(e.g., Boiler #1,
Loop #1)

Areas served
(e.g., floor, rooms)

Date of installation

Total capacity
(gallons)

Usual
temperature
setting
(°F)

Comments/notes: _________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________

24. What is the maximum hot water temperature at the point of delivery permitted by state / local regulations?
_______ °F or _______ °C
25. Are hot water temperatures ever measured by the facility at the points of use?
❑ YES ➔ If yes, obtain copies of the temperature logs
If YES, what is the lowest documented hot water temperature measured at any point within the facility?
_______ °F or _______ °C documented on (Month/Date/Year) ______/______/______
❑ NO
26. Are cold water temperatures ever measured by the facility at the points of use?
❑ YES ➔ If yes, obtain copies of the temperature logs
If YES, what is the highest documented cold water temperature measured at any point within the facility?
_______ °F or _______ °C documented on (Month/Date/Year) ______/______/______
❑ NO
27. Are the potable water disinfectant levels (e.g., chlorine) ever measured by the facility at the points of use?
❑ YES ➔ If yes, obtain copies of the logs
If YES, how often are they measured? ________________________________________________________________
If YES, list the range of disinfectant residuals __________________________________________________________
❑ NO
28. Does the facility have a supplemental disinfection system for long term control of Legionella or other microorganisms?
❑ YES ❑ NO
If YES, obtain SOPs for routine use and maintenance as well as maintenance logs and records of disinfection levels, and
complete the table:
Buildings with
supplemental disinfection

Type of system
(e.g., chlorine, chlorine dioxide,
copper-silver)

Date installed

Describe any maintenance
in the past year
(include routine and emergency)

Comments/Notes: _________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
29. Please describe any maintenance (either routine or emergency) carried out on the potable water system in the past year. Obtain
records/SOPs if available. ___________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________

7 | CDC Legionella Environmental Assessment Form | www.cdc.gov/legionella/outbreak-toolkit/

8 | CDC Legionella Environmental Assessment Form | www.cdc.gov/legionella/outbreak-toolkit/

30. Measured Water System Parameters (see instructions on p. 1)
Copy from table for question 23 (p. 6)

Part of system
(Central heater/ boiler=C

Name of system
Building name

(e.g., incoming water,
Boiler #1, Loop #1)

Proximal
occupant room=P
Distal occupant room=D)

Sampling site
(e.g., heater #1,
hot water tap
in room #436)

Free
chlorine
(ppm)

Maximum
measured
temperature
(°F)

Time to reach
max temp
(min)

APPENDIX A. HEALTHCARE FACILITIES
Note: Complete for all healthcare facilities, including but not limited to hospitals, long term care/rehab/assisted
living/skilled nursing facilities, or clinics.
1. Type of healthcare facility (check all that apply):
❒❒ Acute care hospital
If YES, does the facility have a solid organ or bone marrow transplant program?
❑ YES ❑ NO
❒❒ Long term care facility (i.e., nursing home, long term acute care)
❒❒ Rehabilitation facility or other skilled nursing care
❒❒ Assisted living facility
❒❒ Outpatient surgical center
❒❒ Other outpatient clinic (describe): __________________________________________________________________
❒❒ Other healthcare facility (describe): _________________________________________________________________
2. Number of beds: ___________
3. Are ice machines used to provide ice for patient consumption or processing medical equipment?
❑ YES ❑ NO
If YES, list manufacturer and model or catalog number: _____________________________________________________
4. Has this facility experienced previous Legionnaires’ disease cases that were “possibly” or “definitely” facility-acquired?
❑ YES ❑ NO
If YES, describe (e.g., number of cases, dates): ___________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________

A-1 | CDC Legionella Environmental Assessment Form | Appendix A: Healthcare Facilities

B-1 | CDC Legionella Environmental Assessment Form | Appendix B: Cooling Towers and Evaporative Condensers

APPENDIX B. COOLING TOWERS AND EVAPORATIVE CONDENSERS

Note: It is important to gain an understanding of where the cooling towers are located, how they work, and how they are maintained. Cooling towers
are frequently maintained by an outside contractor, and you may need to contact them directly if facility management does not have an in-depth
knowledge of these systems. Request copies of the maintenance logs.
1. List all cooling towers and evaporative condensers on the facility premises:
Name of device
(e.g., CT1)

Date Installed

Manufacturer

Location of device

Distance to nearest air
intake*/location of the air
intake/ passive or forced

Drift
eliminators
used?

Party responsible for
maintenance

(Y/N)

*intakes to air handling units (AHUs)

2. List details of how each cooling tower is chemically disinfected:
Name of device from
Table 1
(e.g., CT1)

List type/name of
bactericide(s) used

Range in which the bactericide(s)
is regularly maintained
(e.g., 5–10 ppm)

Schedule and method
of adding bactericide
(e.g., daily, weekly, as needed,
automatic, by hand)

Are cooling towers turned off
at any time?
(e.g., seasonally) (Y/N)
If yes, include schedule

B-2 | CDC Legionella Environmental Assessment Form | Appendix B: Cooling Towers and Evaporative Condensers

3. List recent (last 6 months) special (non-routine) treatments, maintenance, or repairs to cooling devices:
Name of device from Table 1
(e.g., CT1)

Action taken

Date

Comments

4. Does the cooling tower water come from a branch of the potable water system inside the facility?
❑ YES ❑ NO
If YES, are backflow prevention devices in place to ensure cooling tower water is not introduced into the potable water system?
❑ YES ❑ NO
If NO, what is the source of water for the cooling towers and evaporative condensers? _____________________________________________________________
_____________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________
5. Can any windows in any occupant rooms or common areas be opened? ❑ YES

❑ NO

If YES, describe which rooms or which buildings have windows that can be opened: _______________________________________________________________
_____________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________

APPENDIX C. WHIRLPOOL SPAS, HOT TUBS, AND HYDROTHERAPY SPAS
Note: Do NOT complete Appendix C for Jacuzzis or whirlpool baths that are filled from the tap and drained after
each use. In many jurisdictions, whirlpool spas are publicly permitted and inspected by the local health authority.
An environmental health specialist with expertise in pool and spa inspection should participate in assessment of
spas and will be aware of local regulations and enforcement powers, as well as have access to a pool sampling
kit. Request copies of the last inspection report as well as routine maintenance logs.
1. Who performs the spa maintenance (e.g., on-site facilities management, name of outside contractor)? ___________________
2. Describe each whirlpool spa and how it is disinfected:
Spa Questions

Spa Descriptor/Location (e.g., main pool, private room #)

Indoor or outdoor?
Max. bather load
Filter type
S = sand
DE = diatomaceous earth,
C = cartridge
Date filter was last changed
Date of last filter backwash
Compensation tank present?
Type of disinfectant used
(include chemical name,
formulation, and amount used)
Current measured disinfectant
level
(e.g., free chlorine, bromine) (ppm)
Current measured pH
Method used for adding
disinfectant
(e.g., automatic feeder, by hand)
Method used for monitoring
and maintaining disinfectant
and pH levels
(e.g., automatic controllers)
Date last drained and scrubbed
Was there a recent disinfectant
“shock” treatment?
Operating as designed and in
good repair?
If no, describe issues.

C-1 | CDC Legionella Environmental Assessment Form | Appendix C: Whirlpool Spas, Hot Tubs, and Hydrotherapy Spas

APPENDIX D. OTHER WATER FEATURES
Note: Complete for decorative fountains, water walls, recreational misters, etc. This can also be modified for
industrial use water. If SOPs and/or maintenance logs exist, request copies.

Water Feature Questions

Water Feature Descriptor/Location
(e.g., lobby fountain, cabana misters)

Indoor or outdoor?

Source of water

Operates continuously (C) or
intermittently (I)
Presence of a heat source?
(e.g., incandescent lighting)
Type of disinfectant used
(include chemical name,
formulation, and amount used)
Current measured disinfectant
level
(e.g., free chlorine, bromine)
(ppm)
Current measured pH

Is there a maintenance
protocol?
Date last cleaned

Operating as designed and in
good repair?
If no, describe issues.

D-1 | CDC Legionella Environmental Assessment Form | Appendix D: Other Water Features

APPENDIX E. RECENT OR ONGOING MAJOR CONSTRUCTION
1. Describe in general the extent of the construction: _________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
2. Was temporary water service provided to the new construction area (i.e., separate meter)?
❑ YES ❑ NO
If YES, describe: _________________________________________________________________________________
______________________________________________________________________________________________
3. Has jack-hammering or pile-driving been used during the construction process?
❑ YES ❑ NO
If YES, list dates and locations: _______________________________________________________________________
______________________________________________________________________________________________
4. Have there been disruptions or changes to the existing potable water system during the construction?
❑ YES ❑ NO
If YES, describe: _________________________________________________________________________________
______________________________________________________________________________________________
5. Has the potable water changed in terms of taste or color during the construction process?
❑ YES ❑ NO
If YES, describe the changes including when they started and ended: ___________________________________________
______________________________________________________________________________________________
6. Is there a standard operating procedure (SOP) for shutting down, isolating, and refilling/flushing for water service areas that
have been subjected to repair and/or construction interruptions?
❑ YES ❑ NO
If YES, briefly describe the steps used in the SOP (attach a copy if possible): ______________________________________
______________________________________________________________________________________________
7. Was the potable water system flushed before occupying the new building space?
❑ YES ❑ NO
If YES, what period of time passed between flushing and when the building was occupied? ___________________________
______________________________________________________________________________________________
8. Complete table on next page.

E-1 | CDC Legionella Environmental Assessment Form | Appendix E: Recent or Ongoing Major Construction

E-2 | CDC Legionella Environmental Assessment Form | Appendix E: Recent or Ongoing Major Construction

8. Complete the table below:

New Building/Wing Name
or Remodeled Area

Date
construction
began

Estimated
date of
completion

Date water
service
began or
restarted*

Relationship to
existing potable
water system

Stories and
Square Feet
Involved

Independent=I
Extension of
existing system=E

(# and Ft2)

*If remodeling of existing structure, include water shut-down date and re-start date.

Uses

(e.g., rooms, dining, recreation,
utilities)
For healthcare:
Inpatient = I
Outpatient = O
Both = B
Intensive Care = ICU
Transplant = Tx

Date
occupants
began
occupying
new or
remodeled
building

Floors
currently
occupied

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

Sample Data Sheet

Public reporting burden of this collection of information is estimated to average 3 hours 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)

Sample Data Sheet

Use this form to keep track of environmental samples taken for Legionella culture during a legionellosis outbreak investigation.
NOTE: this is NOT a chain of custody form.

Sample ID

Date Collected

Specimen Type
(e.g., water,
swab, filter)

Sample Data Sheet | www.cdc.gov/legionella/outbreak-toolkit/
07/2015

CS254961-A

Sample Description (e.g., room 253 shower)

Temp
(ºF)

Free Cl2
(ppm)

Total Cl2
(ppm)

File Type	application/pdf
Author	Christiansen, Abigail E
File Modified	2016-01-21
File Created	2016-01-21