NYC Healthcare Worker Questionnaire

Form Approved

OMB No. 0920-1011

Exp. Date 03/31/2017

Appendix 2: Questions for Healthcare Personnel and Observation Checklist

Questions for doctor/ health practitioner

Who does the preparation of the combination of vancomycin, ceftazidime, and heparin?

Can you walk us through the procedure of how this is done?

How often do you make up a bag of this mixture?

How is it stored?

How many times a day do you draw off of it? Can you explain how you draw from the bag?

Has the refrigerator where it has been stored been functioning normally? Any issues with electricity supply?

What type of training did you receive before you started making this mixture? Do you get any refresher training? If yes, how often?

Who does the preparation of the combination of chemotherapy?

Can you walk us through the procedure of how this is done?

What type of training did you receive before you started making this mixture? Do you get any refresher training? If yes, how often?

What types of infection control precautions do you take when making chemotherapy?

How often is this area where drugs are made up cleaned? With what?

Since when has construction been going on behind the clinic?

Why is the back door left open?

Have you noticed any changes in air quality in the clinic? Any visible mold growth in the last three months?

Any changes in employees since the beginning of 2016?

Any changes in what is used for hand hygiene in the office?

Protocol for prepping area to be injected, including types of antiseptics used?

Protocol for hand hygiene?

Protocol for glove use?

Protocol for mask use?

How many patients received injections with this particular product during a day? A week? A month?

Did you always use single use vial?

Infection Control Practices Observation Checklist

Gloves changed between patients?

Gloves changed between touching patient and environmental surfaces?

Hand hygiene appropriate?

Needles disposed of properly?

Betadyne/alcohol/etc single or multi use?

Use of sterile single use needles?

What disinfectant solution is used at the clinic?

Overall hygiene of the clinic

Do they reconstitute medicine at the clinic in their own pharmacy?

Do they add any other solution to the medication?

What product do they use when they reconstitute the medicine, for example, saline?

Public reporting burden of this collection of information is estimated to average 30 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)