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: |
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3. Sex: Male Female |
4. Employed at Facility since: ______/______/______ |
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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 __________________________ |
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6. Since July 17, 2015 to present, have you worked in any other patient-care facility? Yes No (If no, skip to Section B)
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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 |
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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) |
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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): |
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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 |
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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 |
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16. Please answer the following questions (circle answer) |
Never Always |
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1 2 3 4 5 N/A |
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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? ___ / ___ / ___ |
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19. a. Since July 17, 2015, have you had a sore throat? Yes No (If no, skip to #20)
f. If yes, specify month: _________________ g. If yes, was the result positive? Yes No
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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 __________________ |
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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? ____________________________ |
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22. If you’re feeling sick before a work shift, how do you notify Warren Barr Gold Coast? ___________________________________________
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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!
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 |