Web-Based Survey - Emergency

DRAFT PRO PPT SURVEY
QUESTIONS
11.06.2015

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Table of Contents
Introduction & Notes .................................................................................................................................... 2
Annual Survey ............................................................................................................................................... 3
Hospital Administration Quarterly Survey................................................................................................... 10
Purchasing Quarterly Survey ............................................................................................................................. 11
Safety Quarterly Survey............................................................................................................................... 12
Emergency Preparedness Quarterly Survey ................................................................................................ 13
Infection Control Quarterly Survey.............................................................................................................. 14
Occupational Health Quarterly Survey ........................................................................................................ 17
Emergency Survey ....................................................................................................................................... 19
Crisis Survey ................................................................................................................................................ 20

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Introduction & Notes
This document contains survey questions revised for the contract #200-2015-63553: Monitoring and
Coordinating Personal Protective Equipment (PPE) in Healthcare to Enhance Domestic Preparedness for
Ebola Response.
Several of the matrices in this document are currently undergoing development by the REDCap team.
They are therefore displayed as draft mockups to convey, in general, the user experience.
These questions were drafted prior to the completion of survey development and the MVP
requirements phase. If survey questions change due to new information, an amendment will be
submitted as an update to this list of questions.
Questions for the following surveys are summarized in this document:








Annual: This survey will be completed annually, alongside the hospital. It will be part of hospital
training in the first year and will serve as a checkpoint in years two and three. It is important to
note that someone from VUMC will be completing this survey together, with the participating
hospital.
Quarterly: This survey is separated by hospital area and will most likely be sent to multiple
people. Hospitals can designate who will receive each group of questions.
o Hospital Administration
o Purchasing
o Safety
o Emergency Preparedness
o Infection Control
o Occupational Health
Emergency: The Emergency Survey enables weekly data collection during an emergent scenario,
like a pandemic event that will typically last multiple weeks. There are three questions on this
survey, which will be administered via text message. During the project, hospitals will participate
in a four-week training/testing period to prepare for Emergency data collection.
Crisis: The Crisis Survey is designed for localized, rapid data collection, which will span a short
duration to enable timely decision-making. The Crisis Survey will leverage a text message interface
and will be 1-3 questions maximum.

REDCap branching logic is heavily integrated into these surveys. Asterisks denote questions that will only
display due to branching logic. This document represents the total number of possible questions. In
reality, it will be impossible for a hospital to view them all, due to branching logic.

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Annual Survey
Field Type
Dropdown
Text
Text
Dropdown
Email
Phone
Dropdown

Survey Respondent Information Questions
Hospital CMS Certification Number
First Name
Last Name
Hospital Area
Email Address
Phone Number
Reporting Period

Public reporting burden of this collection of information is estimated to average Baseline Survey is 8 hours and Burden for the Annual Survey is 3 hours per
response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing 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 Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA
(0920-XXXX).

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Field Type
YesNo

Emergency Stockpile Questions
As of the last day in the reporting period, does your hospital maintain an emergency
stockpile of PPT?
*Dropdown In the event of an emergency, where will your hospital obtain extra PPT for
healthcare personnel?
*Dropdown As of the last day in the reporting period, what is your routine for rotating PPT out of
the hospital emergency stockpile?
*Dropdown As of the last day in the reporting period, does your hospital have access to another
source of PPT besides your own hospital emergency stockpile?
*Denotes questions that display according to branching logic.

Field Type
Purchasing Questions
*Text
Other Purchasing Method:
*Denotes questions that display according to branching logic.

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Field Type
Routine Inventory Counts
*Numeric
How many gowns On Hand in House?
*Numeric
How many coveralls On Hand in House?
*Numeric
How many gloves On Hand in House?
*Numeric
How many boot covers On Hand in House?
*Numeric
How many aprons On Hand in House?
*Numeric
How many surgical masks On Hand in House?
*Numeric
How many surgical hoods On Hand in House?
*Numeric
How many face shields On Hand in House?
*Numeric
How many N95s On Hand in House?
*Numeric
How many PAPRs On Hand in House?
*Denotes questions that display according to branching logic.

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Field Type
Emergency Stockpile Inventory Counts
*Numeric
How many gowns in the Emergency Stockpile Inventory?
*Numeric
How many coveralls Emergency Stockpile Inventory?
*Numeric
How many gloves Emergency Stockpile Inventory?
*Numeric
How many boot covers Emergency Stockpile Inventory?
*Numeric
How many aprons Emergency Stockpile Inventory?
*Numeric
How many surgical masks Emergency Stockpile Inventory?
*Numeric
How many surgical hoods Emergency Stockpile Inventory?
*Numeric
How many face shields Emergency Stockpile Inventory?
*Numeric
How many Emergency Stockpile Inventory?
*Numeric
How many PAPRs Emergency Stockpile Inventory?
*Denotes questions that display according to branching logic.

Field Type
Training Inventory Counts
*Numeric
How many gowns in the Training Inventory?
*Numeric
How many coveralls Training Inventory?
*Numeric
How many gloves Training Inventory?
*Numeric
How many boot covers Training Inventory?
*Numeric
How many aprons Training Inventory?
*Numeric
How many surgical masks Training Inventory?
*Numeric
How many surgical hoods Training Inventory?
*Numeric
How many face shields Training Inventory?
*Numeric
How many Training Inventory?
*Numeric
How many PAPRs Training Inventory?
*Denotes questions that display according to branching logic.

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Field Type
Dropdown
Dropdown

Training Questions
Please select your primary fit test respirator
Please select your secondary fit test respirator

Field Type
Numeric

Infectious Disease Questions
Total number of patient AIIRs (Airborne Infection Isolation Rooms) in your hospital,
as of the last day in the reporting period:
What is your added capacity with portable HEPA units, as of the last day in the
reporting period?
Describe your hospitals Ebola tier:

Numeric
Dropdown

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*Note that checkboxes will be disabled for non-applicable options (i.e. diseases without vaccinations,
PUIs for infections other than Ebola, and designated isolation rooms for infections other than Ebola.)

Field Type
*Numeric
*Numeric
*Numeric
*Numeric
*Numeric

HAI Related Activities Questions
How many people are in your Ebola screening group?
How many people are in your MERS screening group?
How many people are in your Measles screening group?
How many people are in your Tuberculosis screening group?
Since the beginning of the fiscal year, how many hospital healthcare personnel have
converted their annual TB skin test and/or QuantiFERON?
*Numeric
How many people are in your Varicella/Disseminated Zoster screening group?
*Numeric
How many people are in your SARS screening group?
*Numeric
How many people are in your Smallpox screening group?
*Numeric
How many people are in your Other screening group?
*Numeric
How many isolation room have you designated?
*Numeric
How many Ebola PUIs did your hospital evaluate?
*Denotes questions that display according to branching logic.

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Field Type
*Dropdown
Numeric

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Program Questions
Please select the immunization(s) you require for your healthcare workers:
Would you be interested in utilizing our data collection tool to help you routinely
survey healthcare personnel regarding their Knowledge, Attitudes, and Beliefs about
wearing a respirator?
Email Address to be contacted with additional information:
Phone Number to be contacted with additional information:

*Email
*Phone
Number
*Email
Contact Email in charge of tracking Knowledge Attitudes and Beliefs:
*Phone
Phone Number in charge of tracking Knowledge Attitudes and Beliefs:
Number
*Denotes questions that display according to branching logic.

Field Type
Numeric
Numeric
Numeric
Numeric
Numeric

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Hospital Statistics Questions
Hospital Admissions for the reporting period:
Staffed Beds for the reporting period:
Number of Patient Days during the reporting period:
As of the last day in the reporting period, how many employees (including providers)
does your hospital have?
As of the last day in the reporting period, how many non-employed providers (LIPS)
work in your hospital?

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Hospital Administration Quarterly Survey
Field Type
Numeric
Numeric
Numeric

Hospital Administration Questions
Patient Days for the reporting period
Hospital Admissions for the reporting period
Hospital Occupancy Rate for the reporting period

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 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 Information Collection Review
Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-XXXX).

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Purchasing Quarterly Survey

*Note that the list of PPT in the first column will be populated based on the hospitals’ selection on the
annual survey.

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Safety Quarterly Survey
Field Type
Numeric
Numeric

Program Questions
As of the last day in the reporting period, how many healthcare personnel are eligible
for the respirator program?
As of the last day in the reporting period, how many healthcare personnel in the
respirator program have completed their annual N95 fit test or PAPR training in the
last year?

*Note that the list of PPT in the first column will be populated based on the hospitals’ selection on the
annual survey.
*This matrix will only be displayed in the event that a hospital indicates via the Annual Survey that their
Safety group purchases from a third party other than their internal purchasing group.

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Emergency Preparedness Quarterly Survey

*Note that the list of PPT in the first column will be populated based on the hospitals’ selection on the
annual survey.
*This matrix will only be displayed in the event that a hospital indicates via the Annual Survey that their
Emergency Preparedness group purchases from a third party other than their internal purchasing group.

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Infection Control Quarterly Survey
Field Type
YesNo
Numeric

Ebola-specific Questions
Did your hospital have any Ebola PUIs (Persons Under Investigation)
How many Ebola PUIs (Persons Under Investigation) did your hospital see during the
reported quarter?

Field Type
*Numeric

Infection Questions
Number of Ebola cases in the reported quarter:

*Numeric
Number of MERS cases in the reported quarter:
*Numeric
Number of Measles cases in the reported quarter:
*Numeric
Number of Tuberculosis cases in the reported quarter:
*Numeric
Number of Varicella/Disseminated Zoster cases in the reported quarter:
*Numeric
Number of SARS cases in the reported quarter:
*Numeric
Number of Smallpox cases in the reported quarter:
*Text
Name of Other Notifiable Infectious Pathogens diagnosed in the reported quarter:
*Numeric
Number of cases of other notifiable infectious pathogens in the reported quarter:
*Denotes questions that display according to branching logic.

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Field Type
*Numeric

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Isolation Questions
Number of Days of Isolation during the reported quarter:

Number of unique patients issued airborne isolation orders during the reported
month:
*Denotes questions that display according to branching logic.
*Numeric

*Note that the answer to the above question will be piped from the annual survey.
Field Type
Checkbox
*Numeric

Training Questions
For which of the following illnesses do you conduct disease-specific training?
How many healthcare personnel are eligible for Ebola training, as of the last day in
the reported quarter?

*Numeric

As of the last day in the reporting quarter, how many healthcare personnel have
completed their Ebola training?
How many healthcare personnel are eligible for MERS training, as of the last day in
the reported quarter?
As of the last day in the reporting quarter, how many healthcare personnel have
completed their MERS training?
How many healthcare personnel are eligible for Measles training, as of the last day in
the reported quarter?

*Numeric
*Numeric
*Numeric

*Numeric
*Numeric

*Numeric
*Numeric

*Numeric
*Numeric

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As of the last day in the reporting quarter, how many healthcare personnel have
completed their Measles training?
How many healthcare personnel are eligible for Tuberculosis training, as of the last
day in the reported quarter?
As of the last day in the reporting quarter, how many healthcare personnel have
completed their Tuberculosis training?
How many healthcare personnel are eligible for Varicella/Disseminated Zoster
training, as of the last day in the reported quarter?
As of the last day in the reporting quarter, how many healthcare personnel have
completed their Varicella/Disseminated Zoster training?
How many healthcare personnel are eligible for SARS training, as of the last day in
the reported quarter?

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*Numeric
*Numeric

*Numeric
*Text
*Numeric

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As of the last day in the reporting quarter, how many healthcare personnel have
completed their SARS training?
How many healthcare personnel are eligible for Smallpox training, as of the last day
in the reported quarter?
As of the last day in the reporting quarter, how many healthcare personnel have
completed their Smallpox training?
Please describe other disease-specific training:
How many healthcare personnel are eligible for other disease-specific training, as of
the last day in the reported quarter?

As of the last day in the reporting quarter, how many healthcare personnel have
completed their disease-specific training?
*Denotes questions that display according to branching logic.
*Numeric

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Occupational Health Quarterly Survey

Field Type
*Numeric
*Numeric
*Numeric
*Numeric
*Numeric
*Numeric
*Numeric
*Text
*Numeric

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Infection Questions
Number of Work-related Ebola cases diagnosed among healthcare personnel in the
reported quarter:
Number of Work-related MERS cases diagnosed among healthcare personnel in the
reported quarter:
Number of Work-related Measles cases diagnosed among healthcare personnel in
the reported quarter:
Number of Work-related Tuberculosis cases diagnosed among healthcare personnel
in the reported quarter:
Number of Work-related Varicella/Disseminated Zoster cases diagnosed among
healthcare personnel in the reported quarter:
Number of Work-related SARS cases diagnosed among healthcare personnel in the
reported quarter:
Number of Work-related Smallpox cases diagnosed among healthcare personnel in
the reported quarter:
Name of Other Work-related illness diagnosed among healthcare personnel in the
reported quarter:
Number of Other Work-related cases diagnosed among healthcare personnel in the
reported quarter:

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Field Type
*Numeric

Infection Questions
Number of unprotected Ebola exposure events in the reported quarter:
(The number of events, not the number of exposed healthcare personnel)
Number of unprotected MERS exposure events in the reported quarter:
*Numeric
(The number of events, not the number of exposed healthcare personnel)
Number of unprotected Measles exposure events in the reported quarter:
*Numeric
(The number of events, not the number of exposed healthcare personnel)
Number of unprotected Tuberculosis exposure events in the reported quarter:
*Numeric
(The number of events, not the number of exposed healthcare personnel)
Number of unprotected Varicella/Disseminated Zoster exposure events in the
*Numeric
reported quarter:
(The number of events, not the number of exposed healthcare personnel)
Number of unprotected SARS exposure events in the reported quarter:
*Numeric
(The number of events, not the number of exposed healthcare personnel)
Number of unprotected Smallpox exposure events in the reported quarter:
*Numeric
(The number of events, not the number of exposed healthcare personnel)
Name of Other Pathogens that were involved in a unprotected exposure events in
*Text
the reported quarter:
Number of unprotected exposure events involving Other Pathogens in the reported
*Numeric
quarter:
(The number of events, not the number of exposed healthcare personnel)
*Denotes questions that display according to branching logic.

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Emergency Survey
Field Type
yesno

Isolation Questions
Has your hospital seen any Ebola PUIs in the last week?

*Numeric
Yesno

How many?
Do you have concerns about your PPT supply?

*Denotes questions that display according to branching logic.

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 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 Information
Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-XXXX).

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Crisis Survey
Question
1

Text Message Questions
Have you experienced defects in the (brand/model) N95 respirator?

2

Do you have experienced shortages in the Impermeable Apron used for your
Ebola Ensemble?
Do you have concerns about your PPT supply?

3

Public reporting burden of this collection of information is estimated to average 10 minutes per response, including the time for reviewing instructions, searching
existing data sources, gathering and maintaining the data needed, and completing 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 Information Collection Review
Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-XXXX).

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