Invasive GAS in LTCF 2016 - Employee Survey

Study ID #: _R

Appendix 1. Invasive GAS in Long Term Care Facility 2016

Employee Survey

Form Approved; OMB No. 0920-1011

Exp. Date 03/31/2017

Date Completed: ____/____/____ □ Check box if documented case

A. Employee Background

1. Name: 2. Age:

3. Sex:  Male  Female

4. Employed at Facility since: ______/______/______

5. List occupation:  Activity aid  Administrative  CNA  Dietary  Food service

 Housekeeping  Laundry  PT/OT  Pharmacist  Physician

 Maintenance  RNA  RN/LPN  Social service  Van driver

 Wound care team  Other __________________________

6. Since July 17, 2015 to present, have you worked in any other patient-care facility?  Yes  No (If no, skip to Section B)

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: ____ / _____ / _______	 Yes  No If yes, date of contact: ____ / _____ / _______	 Strep throat  Impetigo  Cellulitis  Bacteremia/Sepsis  Other, specify: ________________
	Start: ____ / _____ / _______ End: ____ / _____ / _______	 Yes  No If yes, date of contact: ____ / _____ / _______	 Strep throat  Impetigo  Cellulitis  Bacteremia/Sepsis  Other, specify: ________________
	Start: ____ / _____ / _______ End: ____ / _____ / _______	 Yes  No If yes, date of contact: ____ / _____ / _______	 Strep throat  Impetigo  Cellulitis  Bacteremia/Sepsis  Other, specify: ________________

7. a. Since the outbreak, have you had a screening culture for group A Streptococcus?  Yes  No (If no, skip to # 8)

b. If yes, when? ______ / _______ / _______

c. Where was the culture obtained from?  Throat  Rectal  Vaginal  Skin/wound  Other

d. What were the results?  Positive  Negative

B. Job Description at

Warren Barr Gold Coast

8. As part of your job, do you have physical contact with patients?  Yes  No

(If no, skip to Section D)

9. Areas usually worked:  Patient rooms  Nurses’ station  Cafeteria  Rehab floor  Other _____________________

10. Shifts usually worked:  Day  Evening  Night  Other________________________

11. Patient units usually worked:  1  2  3  4  5  6  7  8  Do not work in patient units  All patient units

12. Which days do you usually work (circle ALL that apply):

Sunday

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

13. 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  Bedside incision and debridement aspiration/drainage

 Provide PT/OT  Other beside surgical procedures

C. Work Practice

14. Do you use soap and water to clean your hands?  Yes  No

15. Do you use alcohol-based hand sanitizer to clean your hands?  Yes  No

16. Please answer the following questions (circle answer)

Never Always

1. Do you perform hand hygiene BEFORE physical contact with patients?

1 2 3 4 5 N/A

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

1 2 3 4 5 N/A

3. Do you perform hand hygiene AFTER physical contact with patients?

1 2 3 4 5 N/A

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

1 2 3 4 5 N/A

5. Do you perform hand hygiene BETWEEN contact with patients?

1 2 3 4 5 N/A

6. Do you use the sink or alcohol-based sanitizer in the patient’s room or outside patient’s room?

1 2 3 4 5 N/A

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

1 2 3 4 5 N/A

8. Do you use gloves when changing bandages/dressing wounds?

1 2 3 4 5 N/A

9. If yes, do you change gloves between patients/patient rooms?

1 2 3 4 5 N/A

10. If yes, do you perform hand hygiene before donning gloves?

1 2 3 4 5 N/A

11. If yes, do you perform hand hygiene after removing gloves?   

1 2 3 4 5 N/A

12. Do you use gloves when cleaning soiled patients or linens?

1 2 3 4 5 N/A

13. If yes, do you change gloves between patients/patient rooms?

1 2 3 4 5 N/A

14. If yes, do you perform hand hygiene before donning gloves?

1 2 3 4 5 N/A

15. If yes, do you perform hand hygiene after removing gloves?   

1 2 3 4 5 N/A

16. Do you use person protective equipment (PPE) when bathing patients?

1 2 3 4 5 N/A

17. If yes, please specify type of PPE: ________________________________________________________________

D. Your Health

17. Do you have paid “Sick Leave”?  Yes  No

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

19. a. Since July 17, 2015, have you had a sore throat?  Yes  No (If no, skip to #20)

2. When? ______ / _______ / _______

3. Was a throat swab for testing collected from you?  Yes  No d. If yes, specify month: _________________

5. 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?  Yes  No

8. Were you diagnosed with strep throat?  Yes  No i. If yes, specify month: _________________

10. Did you miss work for this illness?  Yes  No k. How many days did you miss? ____________

12. How many days were you ill? _____________

13. Did you receive antibiotics for this condition?  Yes  No n. If yes, antibiotic name ___________________

20. a. Since July 17, 2015, did you have a rash, open wound, or skin infection?  Yes  No (If no, skip to #21)

b. When? ______ / _______ / _______ c. What was your diagnosis? ____________________________

d. Did you miss work for this illness?  Yes  No How many days did you miss? ____________

f. How many days were you ill? _____________

g. Did you receive antibiotics for this condition?  Yes  No If yes, antibiotic name __________________

21. a. Since July 17, 2015, did you have fever, cough, and/or other respiratory infection?  Yes  No (If no, skip to #22))

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? ____________________________

22. If you’re feeling sick before a work shift, how do you notify Warren Barr Gold Coast? ___________________________________________

23.. 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 July 17, 2015, did anyone in your household have a sore throat?  Yes  No

d. When? ______ / _______ / _______ e. Who (relationship)? ______________________

e. Was he/she diagnosed with strep throat?  Yes  No

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? ______ / _______ / _______

END – Thank you!

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