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----------------------------------------------------------------------------
Gender Male Female
Age ___________ years
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) ______________________
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 |
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Travel history (past year)
Region/country |
Start date (XX/XX/XXXX) |
End date (XX/XX/XXXX) |
Mexico |
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Cape Verde |
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Caribbean (please specify) __________________ |
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Puerto Rico |
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Central America (please specify) __________________ |
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Pacific Islands (please specify) __________________ |
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South American (please specify) __________________ |
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Africa (please specify) __________________ |
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Asia (please specify) __________________ |
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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
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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
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If yes, test |
Symptoms (developed since patient interaction)
Fever Yes No
If yes, dates _________ to __________
Subjective Measured
(Max measured temperature: _______F/C)
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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 |
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Yes |
Call Dr. Rubin for further instructions |
If symptomatic, were symptoms more than 14 days ago?
No |
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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 ________________ |
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Patient care Device reprocessing Environmental cleaning Food service needs Other (please specify) ____________________ |
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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 |
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Did you have any contact with blood or body fluids? Yes No
Body fluid
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What were you doing?
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Was this protected (PPE)?
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What PPE did you typically wear?
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Did you have visible soilage of PPE?
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Areas of contact (pick all that apply)?
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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?
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Did you have visible soilage of PPE?
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Areas of contact (pick all that apply)?
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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)?
|
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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 |