Healthcare Professional Risk Assessment Questionnaire

Form Approved

OMB No. 0920-1011

Exp. Date 03/31/2017

Healthcare Personnel Risk Assessment Questionnaire and Serosurvey for Zika Virus Exposure—Utah, 2016

Public reporting burden of this collection of information is estimated to average 12 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)

Zika Virus Exposure Assessment for

Healthcare Personnel

Date of interview:

Name of interviewer:

Subject name:

Job Title:

Is contact information correct?

If no, please provide

Address:

Phone:

Where was interview administered (circle one)?

Wellness clinic

Phone

Home

Other (please specify)______________

Has sample been collected?

Yes

No

Not indicated at this time

Case or Control (circle one)

Section 1: Demographics, Role----------------------------------------------------------------------------

1. Gender Male Female

2. Age ___________ years

3. Please indicate your job title at this facility

Laboratory staff Environmental services Nurse Radiology tech

Physician/Advanced Care Provider Respiratory therapy Certified nursing assistant/Health care assistant

Other (please specify) ______________________

4. How long have you been working in your current role (at any facility)? _____________ months/years

Section 2: Risks and symptoms----------------------------------------------------------------------------

Country of origin:

Have you lived outside of the US? Yes No

If yes, what countries have you lived in and when did you live there?

Country	Start date	End date

Travel history (past year)

Region/country	Start date (XX/XX/XXXX)	End date (XX/XX/XXXX)
Mexico
Cape Verde
Caribbean (please specify) __________________
Puerto Rico
Central America (please specify) __________________
Pacific Islands (please specify) __________________
South American (please specify) __________________
Africa (please specify) __________________
Asia (please specify) __________________

Vaccination history

Previous vaccinations: Yellow Fever Last dose:

Tick-borne Encephalitis Last dose:

Japanese Encephalitis Last dose:

Pregnancy

Are you or your partner currently pregnant?	Yes No Unknown	If yes, test (group A)
Are you or your partner trying to become pregnant now?	Yes No Unknown	If yes, test (group A)
Are you or your partner planning to become pregnant in the next 6 months?	Yes No Unknown	If yes, test

Symptoms (developed since patient interaction)

Fever Yes No If yes, dates _________ to __________ Subjective Measured (Max measured temperature: _______F/C)	Rash Yes No If yes, dates _________ to __________ Type: Maculopapular Petechial Purpuric Other Pruritic: Yes No Distribution:­­­­­­­_____________________________
Arthralgia Yes No If yes, dates _________ to __________	Conjunctivitis Yes No If yes, dates _________ to __________

Do they have 2 or more symptoms occurring within one week?

If no	Asymptomatic
If yes	Symptomatic

If symptomatic, are you currently symptomatic or have been symptomatic in the past 14 days?

No
Yes	Call Dr. Rubin for further instructions

If symptomatic, were symptoms more than 14 days ago?

No
Yes	If yes, test (group B)

Section 3: Patient Interaction------------------------------------------------------------------------------

Days with any patient interaction?

6/19 6/20 6/22 6/23 6/24 6/25

Site interaction occurred ER ECU Ward ICU Other ________________
Patient care Device reprocessing Environmental cleaning Food service needs Other (please specify) ____________________
Did you enter patient’s room or care area? Yes No	If yes, then low
Did you touch patient? Yes No	If yes, then medium and test (group B)
Did you (circle all that apply): Have any contact with blood or body fluids? Clean up vomit? Clean up stool? Draw blood? Collect urine sample or empty Foley bag? Collect stool sample? Wipe away sweat? Wipe away tears? Suction or manipulate airway? Place Foley? Place or manipulate rectal tube? Reposition the patient? Bathe the patient? Change linens? Perform physical exam? Perform radiology exam or Echo? Device reprocessing? Perform procedure (please specify)?____________________________	If any circled, then high and test (group B)
Cumulative time in room in hours < 1 hour 1 to 2 hours 59 minutes 3 to 5 hours 59 minutes 6 or more hours

Did you have any contact with blood or body fluids? Yes No

Body fluid	What were you doing?	Was this protected (PPE)?	What PPE did you typically wear?	Did you have visible soilage of PPE?	Areas of contact (pick all that apply)?
Blood # times	Phlebotomy Procedure Equipment Soiled linen Contaminated surface Biohazard waste Cleaning Other (please specify)________	Yes No	Face shield Goggles Facemask Respirator/N95 Gloves Gown Other (please specify):__________	Yes No	Protected Not protected Intact skin Broken skin Mucous membranes (please specify)________ Percutaneous exposure Other (please specify_________
Respiratory # times	Phlebotomy Procedure Equipment Soiled linen Contaminated surface Biohazard waste Cleaning Other (please specify)________	Yes No	Face shield Goggles Facemask Respirator/N95 Gloves Gown Other (please specify):__________	Yes No	Protected Not protected Intact skin Broken skin Mucous membranes (please specify)________ Percutaneous exposure Other (please specify_________
Stool # times	Phlebotomy Procedure Equipment Soiled linen Contaminated surface Biohazard waste Cleaning Other (please specify)________	Yes No	Face shield Goggles Facemask Respirator/N95 Gloves Gown Other (please specify):__________	Yes No	Protected Not protected Intact skin Broken skin Mucous membranes (please specify)________ Percutaneous exposure Other (please specify_________

Body fluid	What were you doing?	Was this protected (PPE)?	What PPE did you typically wear?	Did you have visible soilage of PPE?	Areas of contact (pick all that apply)?
Urine # times	Phlebotomy Procedure Equipment Soiled linen Contaminated surface Biohazard waste Cleaning Other (please specify)________	Yes No	Face shield Goggles Facemask Respirator/N95 Gloves Gown Other (please specify):__________	Yes No	Protected Not protected Intact skin Broken skin Mucous membranes (please specify)________ Percutaneous exposure Other (please specify_________
Vomitus # times	Phlebotomy Procedure Equipment Soiled linen Contaminated surface Biohazard waste Cleaning Other (please specify)________	Yes No	Face shield Goggles Facemask Respirator/N95 Gloves Gown Other (please specify):__________	Yes No	Protected Not protected Intact skin Broken skin Mucous membranes (please specify)________ Percutaneous exposure Other (please specify_________
Tears # times	Phlebotomy Procedure Equipment Soiled linen Contaminated surface Biohazard waste Cleaning Other (please specify)________	Yes No	Face shield Goggles Facemask Respirator/N95 Gloves Gown Other (please specify):__________	Yes No	Protected Not protected Intact skin Broken skin Mucous membranes (please specify)________ Percutaneous exposure Other (please specify_________

Body fluid	What were you doing?	Was this protected (PPE)?	What PPE did you typically wear?	Did you have visible soilage of PPE?	Areas of contact (pick all that apply)?
Sweat # times	Phlebotomy Procedure Equipment Soiled linen Contaminated surface Biohazard waste Cleaning Other (please specify)________	Yes No	Face shield Goggles Facemask Respirator/N95 Gloves Gown Other (please specify):__________	Yes No	Protected Not protected Intact skin Broken skin Mucous membranes (please specify)________ Percutaneous exposure Other (please specify_________
Other (Please specify) # times	Phlebotomy Procedure Equipment Soiled linen Contaminated surface Biohazard waste Cleaning Other (please specify)________	Yes No	Face shield Goggles Facemask Respirator/N95 Gloves Gown Other (please specify):__________	Yes No	Protected Not protected Intact skin Broken skin Mucous membranes (please specify)________ Percutaneous exposure Other (please specify_________
Other (Please specify) # times	Phlebotomy Procedure Equipment Soiled linen Contaminated surface Biohazard waste Cleaning Other (please specify)________	Yes No	Face shield Goggles Facemask Respirator/N95 Gloves Gown Other (please specify):__________	Yes No	Protected Not protected Intact skin Broken skin Mucous membranes (please specify)________ Percutaneous exposure Other (please specify_________

Were you involved with any procedures (either performing or in room)?
Intubation	Performed or assisted with procedure Present in room	Face shield Goggles Facemask Respirator/N95 Gloves Gown Other (please specify): _______________________
Central line placement	Performed or assisted with procedure Present in room	Face shield Goggles Facemask Respirator/N95 Gloves Gown Other (please specify): _______________________
Bronchoscopy	Performed or assisted with procedure Present in room	Face shield Goggles Facemask Respirator/N95 Gloves Gown Other (please specify): _______________________
CPR	Performed or assisted with procedure Present in room	Face shield Goggles Facemask Respirator/N95 Gloves Gown Other (please specify): _______________________
Sputum induction	Performed or assisted with procedure Present in room	Face shield Goggles Facemask Respirator/N95 Gloves Gown Other (please specify): _______________________
Extubation	Performed or assisted with procedure Present in room	Face shield Goggles Facemask Respirator/N95 Gloves Gown Other (please specify): _______________________
Airway suctioning	Performed or assisted with procedure Present in room	Face shield Goggles Facemask Respirator/N95 Gloves Gown Other (please specify): _______________________
Nasogastric tube placement	Performed or assisted with procedure Present in room	Face shield Goggles Facemask Respirator/N95 Gloves Gown Other (please specify): _______________________
Nebulizer treatment	Performed or assisted with procedure Present in room	Face shield Goggles Facemask Respirator/N95 Gloves Gown Other (please specify): _______________________
Dialysis	Performed or assisted with procedure Present in room	Face shield Goggles Facemask Respirator/N95 Gloves Gown Other (please specify): _______________________
Rectal tube placement or manipulation	Performed or assisted with procedure Present in room	Face shield Goggles Facemask Respirator/N95 Gloves Gown Other (please specify): _______________________
Arterial line placement	Performed or assisted with procedure Present in room	Face shield Goggles Facemask Respirator/N95 Gloves Gown Other (please specify): _______________________
Peripheral IV placement	Performed or assisted with procedure Present in room	Face shield Goggles Facemask Respirator/N95 Gloves Gown Other (please specify): _______________________
Noninvasive ventilation	Performed or assisted with procedure Present in room	Face shield Goggles Facemask Respirator/N95 Gloves Gown Other (please specify): _______________________
Lumbar puncture	Performed or assisted with procedure Present in room	Face shield Goggles Facemask Respirator/N95 Gloves Gown Other (please specify): _______________________
Other (please specify) _______________	Performed or assisted with procedure Present in room	Face shield Goggles Facemask Respirator/N95 Gloves Gown Other (please specify): _______________________

Did you come into contact with body following death? Yes No

Did you have any other contact with the patient not previously mentioned?

Section 4: PPE training---------------------------------------------------------------------------------------

Have you received training on proper selection of PPE for standard precautions? Yes No

Have you received training on how to don:

Gloves? Yes No

Gown? Yes No

Eye protection? Yes No

Have you received training on how to doff (so as not to contaminate):

Gloves? Yes No

Gown? Yes No

Eye protection? Yes No

How often does this training occur? ______________________________________

When did you last receive training? ______________________________________

Were you required to demonstrate competency? Yes No

File Type	application/vnd.openxmlformats-officedocument.wordprocessingml.document
Author	Novosad, Shannon A. (CDC/OPHSS/CSELS) (CTR)
File Modified	0000-00-00
File Created	2021-01-23