Form 0920-20MZ Assessment of Healthcare Personnel

F orm Approved

OMB No. 0920-XXXX

Exp. Date: XX/XX/2020

Version:

A ssessment of Healthcare Personnel

Exposed to or Infected with SARS-CoV-2

EIP HCP ID: _______________ IF PUI or COVID-19 CASE, ENTER STATE OR CDC ID: _____________

CDC estimates the average public reporting burden for this collection of information as 30 minutes per response, including the time for reviewing instructions, searching existing data/information sources, gathering and maintaining the data/information 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 Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-XXXX).

1. INTERVIEWER INFORMATION

1. Date of interview and form completion: MM / DD / YYYY

2. Interviewer name Last: ________________________ First: _________________________ Affiliation: _________________________

Last: ________________________ First: _________________________ Affiliation: _________________________

2. HEALTHCARE PERSONNEL (HCP) IDENTIFIERS (NOT TO BE TRANSMITTED TO CDC)

3. HCP Name: Last: ________________________ First: _________________________ 4. Phone no.:(________)____________________

5. HCP address: _______________________________________City: ________________________State: ____________ ZIP: ____________

6. Facility Name: 1_______________________________________________________________________________________________________

2_______________________________________________________________________________________________________

3_______________________________________________________________________________________________________

4_______________________________________________________________________________________________________

3. HCP CASE STATUS INFORMATION

READ ME FIRST! Answer all questions on this form to the best of your knowledge. For dates, use a calendar (one is included) and any additional documentation or information you have available to help you remember and records dates as accurately as possible

5. Are you a healthcare personnel? (Refer to definition of healthcare personnel in the box)

Healthcare Personnel (HCP) refers to all paid and unpaid persons serving in healthcare settings who have the potential for direct or indirect exposure to patients or infectious materials, including:

• body substances

• contaminated medical supplies, devices, and equipment

• contaminated environmental surfaces

• contaminated air

For example, this includes any employee or contractor of a healthcare facility such as physicians, nurses, students, respiratory therapists, phlebotomists, laboratory staff, as well as transport, food service, housekeeping, volunteers, and maintenance personnel.

Yes

No

Not sure

5. Have you been diagnosed with COVID-19?

Yes

No

Not sure

5. Have you been tested for coronavirus (also known as SARS-CoV-2), the virus that causes COVID-19?

Yes

No; STOP the interview or form completion

Not sure

5. Did someone (for example a doctor, nurse, or lab technician) collect swab(s) from your nose and/or throat for coronavirus (SARS-CoV-2) testing?

Yes; answer Q10a

No; go to Q11

Not sure; go to Q11

10a. What was the coronavirus test result of the swab(s)? (if they collected swabs from you more than once, check “Positive” if at least one of the swabs tested positive for coronavirus; check “Negative” only if all swabs tested negative for coronavirus)

I was not told of my results

Positive; answer Q10b

Negative; answer Q10c

My results were unclear

10b. When did they collect the first swab that tested positive? MM / DD / YYYY Not sure

10c. When did they collect the most recent swab that tested negative? MM / DD / YYYY Not sure

5. Did someone (for example a doctor, nurse, or lab technician) collect blood from you for coronavirus (SARS-CoV-2) testing?

Yes; answer Q11a

No; to go Q12

Not sure; go to Q12

11a. What was the test result of your blood? (if they collected blood from you more than once, check “Positive” if at least one blood test was positive; check “Negative” only if all blood tests were negative)

I was not told of my results

Positive; answer Q11b and Q11c

Negative; go to Q11d

My results were unclear

11b. Was your result positive for IgM or IgG antibodies? IgM IgG Not sure

11 c. When did they collect the first positive blood sample? MM / DD / YYYY Not sure

11d. When did they collect the most recent negative blood sample? MM / DD / YYYY Not sure

• A person with suspected COVID-19 is someone who has symptoms consistent with COVID-19, such as fever, cough, sore throat, runny nose, or shortness of breath but has not had a laboratory test for SARS-CoV-2

• A person with confirmed COVID-19 is someone who has a positive laboratory test for SARS-CoV-2

• For this interview, a “person with COVID-19” or a “COVID-19 patient” means a person with suspected or confirmed COVID-19.

• For this interview, close contact means: a) being within approximately 6 feet (2 meters) of a person with COVID-19 for at least a few minutes (such as caring for or visiting the patient; or sitting within 6 feet of the patient in a healthcare waiting area or room); or b) having unprotected direct contact with infectious secretions or excretions of the patient (e.g., being coughed on, touching used tissues with a bare hand).

5. Did you have any close contact with a person(s)

with COVID-19? (Refer to the definitions in the box)

Yes; answer Q12a

No; go to Q13

Not sure; go to Q13

12a. Did the close contact occur in the healthcare

facility where you work?

Yes; answer Q12b, Q12c, and Q12d

No; go to Q13

Not sure; go to Q13

12b. When was your first close contact with a

person(s) with COVID-19 in the healthcare

facility where you work?

MM / DD / YYYY Not sure

12c. When was your last close contact with a person(s) with COVID-19 in the healthcare facility that you work? (record interview date or today’s date if close contact is still occurring) MM / DD / YYYY Not sure

12d. Did your facility inform you of the exposure risk level of your close contact with a person(s) with COVID-19?

Yes; answer Q12d1

No

Not sure

12d1. What was your exposure risk level? High / Medium / Low / Not sure

5. Have you had any of the symptoms in the table below?

No; go to Q15

Yes; check all symptoms in the table below that apply; provide onset and resolution date for any symptom you had; write interview or form completion date as resolution date if you still have the symptoms.

• If you have been diagnosed with COVID-19, check the symptoms you had during the 14 days before or on the specimen collection date of your first positive coronavirus test. For example, if you had a nasal swab for coronavirus testing done on April 15, check any symptoms you had from April 1 through April 15. (MM / DD / YYYY to MM / DD / YYYY)

• If you have NOT been diagnosed with COVID-19, check the symptoms you had during the 14 days before or on the specimen collection date of your most recent NEGATIVE coronavirus test result. (MM / DD / YYYY to MM / DD / YYYY)

Symptom	When did the symptom begin?	When did the symptom end?
Felt feverish	MM / DD / YYYY Not sure	MM / DD / YYYY Not sure
Documented fever ≥100.0°F	MM / DD / YYYY Not sure	MM / DD / YYYY Not sure
Chills	MM / DD / YYYY Not sure	MM / DD / YYYY Not sure
Dry cough	MM / DD / YYYY Not sure	MM / DD / YYYY Not sure
Productive cough	MM / DD / YYYY Not sure	MM / DD / YYYY Not sure
Sore throat	MM / DD / YYYY Not sure	MM / DD / YYYY Not sure
Runny nose	MM / DD / YYYY Not sure	MM / DD / YYYY Not sure
Shortness of breath	MM / DD / YYYY Not sure	MM / DD / YYYY Not sure
Muscle aches	MM / DD / YYYY Not sure	MM / DD / YYYY Not sure
Headache	MM / DD / YYYY Not sure	MM / DD / YYYY Not sure
Nausea or vomiting	MM / DD / YYYY Not sure	MM / DD / YYYY Not sure
Diarrhea	MM / DD / YYYY Not sure	MM / DD / YYYY Not sure
Abdominal pain	MM / DD / YYYY Not sure	MM / DD / YYYY Not sure
Altered sense of smell or taste	MM / DD / YYYY Not sure	MM / DD / YYYY Not sure
Other, ___________________________	MM / DD / YYYY Not sure	MM / DD / YYYY Not sure
Other, ___________________________	MM / DD / YYYY Not sure	MM / DD / YYYY Not sure
Other, ___________________________	MM / DD / YYYY Not sure	MM / DD / YYYY Not sure
Other, ___________________________	MM / DD / YYYY Not sure	MM / DD / YYYY Not sure

5. Based on the information on symptom dates in the table above, when was the first date you started to have COVID-19 symptom(s)? MM / DD / YYYY Not sure

4. HCP COMMUNITY EXPOSURES

READ ME FIRST (EIP Interview Instruction Only)

• If the HCP was diagnosed with COVID-19 and had symptoms, complete Questions #15–39 with information for the 14 days before and the day of symptom onset (MM / DD / YYYY to MM / DD / YYYY)

• If the HCP was diagnosed with COVID-19 and did NOT have symptoms, complete Questions #15–39 with information for the 14 days before the specimen collection date of the first positive coronavirus test

(MM / DD / YYYY to MM / DD / YYYY)

• If the HCP was NOT diagnosed with COVID-19 and had symptoms, complete Questions #15–39 with information for the14 days before and the day of symptom onset (MM / DD / YYYY to MM / DD / YYYY)

• If the HCP was NOT diagnosed with COVID-19 and did NOT have symptoms, complete Questions #16–40 with information for the 14 days before the specimen collection date of the most recent NEGATIVE coronavirus test result (MM / DD / YYYY to MM / DD / YYYY)

5. Did you have close contact with a person(s) with COVID-19 outside of the healthcare facility(ies) where you work?

Yes; answer Q15a, Q15b, and Q15c

No; go to Q16

Not sure; go to Q16

15a. When did you first and last have close contact with a person(s) with COVID-19 outside of the facility(ies)?

Date of first close contact MM / DD / YYYY Not sure

Date of last close contact MM / DD / YYYY Not sure

15b. What is your relationship to the person(s) with COVID-19? (Check all that apply)

Spouse/partner Child Parent Other family Friend Medical provider Co-worker
Classmate Roommate Contact only – no relationship Other; can you specify? _________________

15c. Where did the close contact with a person(s) with COVID-19 occur? (Check all that apply)

Household Work Daycare School/University Transit Rideshare Hotel

Cruise Ship Healthcare facility Other; can you specify? _____________________________________________

5. Did you travel away from home? (Check “Yes” if your return date is during the 14 days from MM / DD / YYYY to MM / DD / YYYY date range defined in guidance at top of page 5)

Yes—domestic travel; can you specify destination(s)? ______________________________________________________

Yes—international travel; can you specify destination(s)? __________________________________________________

No

Not sure

5. Did any of the following situations apply to you? If “Yes,” provide start and end dates for each situation.

Did you…	Answer	Date Range
…have any household members, friends, acquaintances, or co-workers who had fever or respiratory symptoms (for example, cough, sore throat, etc.)?	Yes No Not sure	From: MM / DD / YYYY To: MM / DD / YYYY Not sure
…have close contact (such as caring for, speaking with, or touching) with any ill persons outside a healthcare facility?	Yes No Not sure	From: MM / DD / YYYY To: MM / DD / YYYY Not sure
…attend a mass gathering (such as a religious event, wedding, party, dance, concert, banquet, festival, sports event, or other event)?	Yes No Not sure	From: MM / DD / YYYY To: MM / DD / YYYY Not sure
…use public transportation (for example, a bus, train, airplane)	Yes No Not sure	From: MM / DD / YYYY To: MM / DD / YYYY Not sure
…use shared transportation (such as a car or van pool, ride share service)	Yes No Not sure	From: MM / DD / YYYY To: MM / DD / YYYY Not sure
…attend or work at a school or daycare?	Yes No Not sure	From: MM / DD / YYYY To: MM / DD / YYYY Not sure
…have a household member who attended school or daycare?	Yes No Not sure	From: MM / DD / YYYY To: MM / DD / YYYY Not sure
…have close contact with a sick person who had contact with a person with COVID-19?	Yes No Not sure	From: MM / DD / YYYY To: MM / DD / YYYY Not sure
…have close contact with a person who travelled internationally in the past 2 weeks?	Yes No Not sure	From: MM / DD / YYYY To: MM / DD / YYYY Not sure
…have close contact with a person who had a fever and/or other flu-like symptoms such as cough, runny nose, or sore throat and international travel in the preceding 2 weeks?	Yes No Not sure If “Yes,” where did the person travel? ___________________________ ___________________________	From: MM / DD / YYYY To: MM / DD / YYYY Not sure

5. HCP EXPOSURES AND PATIENT CARE ACTIVITIES DURING WORK IN HEALTHCARE FACILITY

5. What is your role(s) in the healthcare facility(ies) where you work? (Check all that apply)

Chaplain	Licensed practical nurse	Physician assistant
Environmental services worker	Medical assistant	Physician (intern/resident)
Facilities/maintenance worker	Nursing assistant	Physician (fellow)
Food services worker	Nutritionist	Respiratory therapist
Laboratory personnel	Occupational therapist	Registered nurse
Cytotechnologist	Pharmacist or pharmacy personnel	Speech therapist
Histotechnologist	Phlebotomist	Student
Medical/Clinical Lab Scientist	Physician (attending)	Ward clerk
PhD laboratory scientist	Physical therapist
Other laboratory personnel	Other; can you specify? __________________________________________________
Medical Laboratory Technician

5. What type of healthcare facility(ies) do you work in? (Check all that apply)

   Hospital (including hospital emergency department)	Outpatient dialysis unit or center
   Free-standing emergency room/department	Nursing home or skilled nursing facility
   Urgent care clinic	Other; can you specify? ______________________
   Outpatient clinic; can you specify clinic type? __________________________________________________________________

6. In which area(s) of the facility(ies) do you normally work? (Check all that apply)

Emergency room/department	Laboratory	Outpatient clinic area
Endoscopy room	Clinical pathology	Pharmacy
Intensive care unit	Anatomic pathology	Reception area
Inpatient ward	Other laboratory type	Radiology department
Unknown	Operating room	Other; can you specify? _______________

5. Did you have any close contacts with COVID-19 patient(s) during work in your facility?

Yes

No; go to Q38

Not sure; go to Q38

5. In which area(s) of the facility did your close contacts with COVID-19 patient(s) occur? (Check all that apply)

During transport	Laboratory
Emergency room examination room	Operating room
Endoscopy room	Outpatient examination room
Inpatient ward patient room	Radiology department
Intensive care unit patient room	Reception area
Not sure	Other; can you specify? ______________________

5. Which of the following activities did you perform with COVID-19 patient(s)? (Check all that apply)

   Arterial blood gas collection	Insertion of nasogastric tube
   Bathing	Insertion of peripheral line
   Changing linen	Lifting or positioning
   Chest tube (insert or remove)	Manipulation of oxygen face mask or tubing
   Cleaning the room	Manipulation of ventilator or tubing
   Collecting respiratory specimens	Participating in surgery
   Drawing blood	Performing physical exam
   Extracorporeal Membrane Oxygenation (ECMO)	Performing X-ray
   Emptying bedpan	Placing urinary catheter
   Feeding	Providing medication
   Giving injection	Taking vital signs
   Hemodialysis	Tracheostomy care
   Insertion of central line	Transport in the facility
   Other; can you specify? _________________________________________

6. What Personal Protective Equipment (PPE) were you wearing during the above patient care activities for COVID-19 patient(s)? (Check the frequency of use for each PPE item)

Reminder!

For this interview, a “COVID-19 patient” is a person with suspected or confirmed COVID-19.

Gloves	All the time	Most of the time	Sometimes	Rarely or never
Gown	All the time	Most of the time	Sometimes	Rarely or never
N95 respiratory	All the time	Most of the time	Sometimes	Rarely or never
PAPR	All the time	Most of the time	Sometimes	Rarely or never
Facemask	All the time	Most of the time	Sometimes	Rarely or never
Goggles/face shield	All the time	Most of the time	Sometimes	Rarely or never

6. HCP PARTICIPATION IN AEROSOL-GENERATING PROCEDURES DURING WORK IN HEALTHCARE FACILITY

5. Examples of aerosol generating procedures

   Airway suctioning

   Breaking ventilation circuit (intentionally or unintentionally)

   Bronchoscopy

   Chest physiotherapy

   Code / CPR

   High-flow oxygen delivery

   High-frequency oscillatory ventilation (HFOV)

   Intubation

   Mini-bronchoalveolar lavage (BAL)

   Manual (bag) ventilation

   Nebulizer treatments

   Non-invasive positive-pressure ventilation (NIPPV, e.g., BiPAP, CPAP)

   Other aerosol generating procedures

   Sputum induction

   Did you participate in any aerosol-generating procedures (AGPs) for COVID-19 patient(s)? (Refer to examples of AGPs in the table)

Yes; answer Q25a

No; go to Q26

Not sure; go to Q26

25a. Which of the following aerosol generating procedures (AGPs) did you perform, assist with, or were you present in the room for, with a COVID-19 patient(s)? (Check all that apply; for each procedure selected, indicate if you performed/assisted or were present in room, number of procedures, average length of procedure, personal protective equipment [PPE] used, and frequency of PPE use)

Procedure

PPE Frequency of use

Airway suctioning

Performed or assisted Present in room

Number of procedures: ___________________

Average length of procedure: _______________minutes

Gloves	All the time	Most of the time	Sometimes	Rarely or never
Gown	All the time	Most of the time	Sometimes	Rarely or never
N95 respirator	All the time	Most of the time	Sometimes	Rarely or never
PAPR	All the time	Most of the time	Sometimes	Rarely or never
Facemask	All the time	Most of the time	Sometimes	Rarely or never
Goggles or face shield	All the time	Most of the time	Sometimes	Rarely or never

Non-invasive positive-pressure ventilation (NIPPV, e.g., BiPAP, CPAP)

Performed or assisted Present in room

Time spent in room during NIPPV: ______________minutes

Gloves	All the time	Most of the time	Sometimes	Rarely or never
Gown	All the time	Most of the time	Sometimes	Rarely or never
N95 respirator	All the time	Most of the time	Sometimes	Rarely or never
PAPR	All the time	Most of the time	Sometimes	Rarely or never
Facemask	All the time	Most of the time	Sometimes	Rarely or never
Goggles or face shield	All the time	Most of the time	Sometimes	Rarely or never

Manual (bag) ventilation

Performed or assisted Present in room

Number of procedures: ____________________

Average length of procedure: ________________ minutes

Gloves	All the time	Most of the time	Sometimes	Rarely or never
Gown	All the time	Most of the time	Sometimes	Rarely or never
N95 respirator	All the time	Most of the time	Sometimes	Rarely or never
PAPR	All the time	Most of the time	Sometimes	Rarely or never
Facemask	All the time	Most of the time	Sometimes	Rarely or never
Goggles or face shield	All the time	Most of the time	Sometimes	Rarely or never

Nebulizer treatments

Performed or assisted Present in room

Number of procedures: _____________________

Average length of procedure: ________________minutes

Gloves	All the time	Most of the time	Sometimes	Rarely or never
Gown	All the time	Most of the time	Sometimes	Rarely or never
N95 respirator	All the time	Most of the time	Sometimes	Rarely or never
PAPR	All the time	Most of the time	Sometimes	Rarely or never
Facemask	All the time	Most of the time	Sometimes	Rarely or never
Goggles or face shield	All the time	Most of the time	Sometimes	Rarely or never

Intubation

Performed or assisted Present in room

Number of procedures: _____________________

Average length of procedure: ________________minutes

Gloves	All the time	Most of the time	Sometimes	Rarely or never
Gown	All the time	Most of the time	Sometimes	Rarely or never
N95 respirator	All the time	Most of the time	Sometimes	Rarely or never
PAPR	All the time	Most of the time	Sometimes	Rarely or never
Facemask	All the time	Most of the time	Sometimes	Rarely or never
Goggles or face shield	All the time	Most of the time	Sometimes	Rarely or never

High-frequency oscillatory ventilation (HFOV)

Performed or assisted Present in room

Time spent in room during HFOV: ______________minutes

Gloves	All the time	Most of the time	Sometimes	Rarely or never
Gown	All the time	Most of the time	Sometimes	Rarely or never
N95 respirator	All the time	Most of the time	Sometimes	Rarely or never
PAPR	All the time	Most of the time	Sometimes	Rarely or never
Facemask	All the time	Most of the time	Sometimes	Rarely or never
Goggles or face shield	All the time	Most of the time	Sometimes	Rarely or never

Chest physiotherapy

Performed or assisted Present in room

Number of procedures: _____________________

Average length of procedure: ________________minutes

Gloves	All the time	Most of the time	Sometimes	Rarely or never
Gown	All the time	Most of the time	Sometimes	Rarely or never
N95 respirator	All the time	Most of the time	Sometimes	Rarely or never
PAPR	All the time	Most of the time	Sometimes	Rarely or never
Facemask	All the time	Most of the time	Sometimes	Rarely or never
Goggles or face shield	All the time	Most of the time	Sometimes	Rarely or never

Mini-bronchoalveolar lavage (BAL)

Performed or assisted Present in room

Number of procedures: _____________________

Average length of procedure: ________________minutes

Gloves	All the time	Most of the time	Sometimes	Rarely or never
Gown	All the time	Most of the time	Sometimes	Rarely or never
N95 respirator	All the time	Most of the time	Sometimes	Rarely or never
PAPR	All the time	Most of the time	Sometimes	Rarely or never
Facemask	All the time	Most of the time	Sometimes	Rarely or never
Goggles or face shield	All the time	Most of the time	Sometimes	Rarely or never

Breaking ventilation circuit (intentionally or unintentionally)

Performed or assisted Present in room

Number of disconnections: __________________

Average duration of each disconnection: __________minutes

Gloves	All the time	Most of the time	Sometimes	Rarely or never
Gown	All the time	Most of the time	Sometimes	Rarely or never
N95 respirator	All the time	Most of the time	Sometimes	Rarely or never
PAPR	All the time	Most of the time	Sometimes	Rarely or never
Facemask	All the time	Most of the time	Sometimes	Rarely or never
Goggles or face shield	All the time	Most of the time	Sometimes	Rarely or never

Sputum induction

Performed or assisted Present in room

Number of procedures: _____________________

Average length of procedure: ________________minutes

Gloves	All the time	Most of the time	Sometimes	Rarely or never
Gown	All the time	Most of the time	Sometimes	Rarely or never
N95 respirator	All the time	Most of the time	Sometimes	Rarely or never
PAPR	All the time	Most of the time	Sometimes	Rarely or never
Facemask	All the time	Most of the time	Sometimes	Rarely or never
Goggles or face shield	All the time	Most of the time	Sometimes	Rarely or never

Bronchoscopy

Performed or assisted Present in room

Number of procedures: _____________________

Average length of procedure: ________________minutes

Gloves	All the time	Most of the time	Sometimes	Rarely or never
Gown	All the time	Most of the time	Sometimes	Rarely or never
N95 respirator	All the time	Most of the time	Sometimes	Rarely or never
PAPR	All the time	Most of the time	Sometimes	Rarely or never
Facemask	All the time	Most of the time	Sometimes	Rarely or never
Goggles or face shield	All the time	Most of the time	Sometimes	Rarely or never

High-flow oxygen delivery

Performed or assisted Present in room

Time in room during delivery: __________________minutes

Gloves	All the time	Most of the time	Sometimes	Rarely or never
Gown	All the time	Most of the time	Sometimes	Rarely or never
N95 respirator	All the time	Most of the time	Sometimes	Rarely or never
PAPR	All the time	Most of the time	Sometimes	Rarely or never
Facemask	All the time	Most of the time	Sometimes	Rarely or never
Goggles or face shield	All the time	Most of the time	Sometimes	Rarely or never

Other AGP; can you specify? ________________________________________

Performed or assisted Present in room

Time in room during AGP: __________________minutes

Gloves	All the time	Most of the time	Sometimes	Rarely or never
Gown	All the time	Most of the time	Sometimes	Rarely or never
N95 respirator	All the time	Most of the time	Sometimes	Rarely or never
PAPR	All the time	Most of the time	Sometimes	Rarely or never
Facemask	All the time	Most of the time	Sometimes	Rarely or never
Goggles or face shield	All the time	Most of the time	Sometimes	Rarely or never

5. What is the longest single (continuous) amount of time were you in a room or other location with COVID-19 patient(s)?

Two minutes or less Between 2 and 15 minutes Between 15 and 30 minutes

Between 30 and 60 minutes More than 60 minutes Not sure

5. What is the total amount of time that you were in a room or other location with COVID-19 patient(s)?

Estimated: ____________________minutes Not sure

5. How close did you get to the COVID-19 patient(s)? (if you saw more than one COVID-19 patient and/or had more than one interaction with COVID-19patient(s), give the closest distance)

Within 6 feet or less More than 6 feet away at all times Not sure

5. How often were COVID-19 patient(s) wearing a facemask or were they intubated (i.e., have a tube inserted into their lungs for breathing) when you had contact with them? (Do not count masks used for delivery of oxygen or non-invasive positive pressure ventilation)

All the time Most of the time Sometimes Rarely or never Not sure

29a. Which of the following was in place on COVID-19 patient(s) during your contacts?

Surgical mask N95 respirator (mask with closer fit) Intubation (i.e., tube for breathing)

Other; can you specify? _______________________________________________ Not sure

5. How often were COVID-19 patient(s) in an Airborne Infection Isolation Room (AIIR) (i.e., negative pressure room used for isolation) when you had contact with them?

All the time Most of the time Sometimes Rarely or never Not sure

5. Did you have any concerns about your own PPE use during care for COVID-19 patient(s) (for example, did you have tears in your PPE, or did you need to change or replace your PPE while in the patient room)?

Yes; can you describe your concern(s)?___________________________________________________________________

No

Not sure

5. Did you reuse a respirator (for example, N95 respirator) during care for COVID-19 patient(s)? (Reuse means the practice of using the same respirator [usually a N95 respirator] for multiple encounters with patients but removing it [doffing] after each encounter and storing it between encounters)

Yes No Not sure Did not use a respirator

5. Were you fit tested for a respirator (for example, a N95 respirator)?

Yes; answer Q33a

No; go to Q34

Not sure; go to Q34

35a. Were you able to wear the respirator that you were fit tested for?

Yes No Not sure

5. Did you have any exposures of your mucous membranes (for example, your mouth or eyes) or skin to COVID-19 patient's respiratory secretions (i.e., liquid from mouth or nose), blood or other body fluids?

Yes; can you specify the fluid to which you were exposed? _________________________________________

No

Not sure

5. Did you have any percutaneous exposures (e.g., needle sticks or cuts) to COVID-19 patient's respiratory secretions (i.e., liquid from mouth or nose), blood or other body fluids?
   Yes; can specify the fluid to which you were exposed? ________________________________________ _

No

Not sure

5. Did you have any direct skin-to-skin contact(s) with COVID-19 patient(s)?
   Yes No Not sure

5. How would you describe your hand hygiene compliance (i.e., following hand washing guidance) during care for COVID-19 patient(s) or working in the room of COVID-19 patients?

All the time Most of the time Sometimes Rarely or never

5. In your normal workday, how often were you able to practice social distancing with your co-workers? Social distancing means staying 6 feet away from other persons.

All the time Most of the time Sometimes Rarely or never

5. How often did you practice universal masking at work (e.g., wearing any type of mask for the entire shift)?

All the time Most of the time Sometimes Rarely or never

7. HCP DEMOGRAPHIC AND UNDERLYING MEDICAL CONDITIONS

5. What is your sex at birth? Male Female Prefer not to answer

5. How old are you? _______ years Prefer not to answer

5. What is your height? ___________ feet _________ inches Prefer not to answer

5. What is your weight? ______________________ pounds Prefer not to answer

5. How would you define your race? (Check all that apply)

American Indian or Alaska Native Black or African American White

Native Hawaiian/other Pacific Islander Asian Other race

Prefer not to answer

5. How would you define your ethnicity? (Check one)

Hispanic or Latino Not Hispanic or Latino Prefer not to answer

5. Do you have any of the following underlying conditions?

Asthma	Yes	No	Unknown	Prefer not to answer
Allergic rhinitis	Yes	No	Unknown	Prefer not to answer
Chronic Obstructive Pulmonary Disease (COPD)	Yes	No	Unknown	Prefer not to answer
Chronic lung disease, other	Yes; can you specify? __________________________________	No	Unknown	Prefer not to answer
Hypertension	Yes	No	Unknown	Prefer not to answer
Heart condition	Yes; can you specify? __________________________________	No	Unknown	Prefer not to answer
Diabetes mellitus	Yes	No	Unknown	Prefer not to answer
Chronic kidney disease	Yes	No	Unknown	Prefer not to answer
Hemodialysis	Yes	No	Unknown	Prefer not to answer
Autoimmune or rheumatologic disease	Yes; can you specify? __________________________________	No	Unknown	Prefer not to answer
Active cancer	Yes; can you specify? __________________________________	No	Unknown	Prefer not to answer
Solid organ transplant	Yes; can you specify? __________________________________	No	Unknown	Prefer not to answer
Hematopoietic stem cell transplant	Yes	No	Unknown	Prefer not to answer
Other immunosuppressing condition	Yes; can you specify? __________________________________	No	Unknown	Prefer not to answer
Chronic liver disease	Yes	No	Unknown	Prefer not to answer
Pregnancy	Yes; can you specify weeks? ________________________	No	Unknown	Prefer not to answer
Other medical condition(s)	Yes; can you specify? __________________________________	No	Unknown	Prefer not to answer

5. Are you taking any immunosuppressant medications (i.e., medications to reduce your body’s immune response like corticosteroids, chemotherapy, or other medications)?

Yes; can you specify? ______________________________________________________________________________________

No

Prefer not to answer

5. Are you taking any other medications?

Yes; can you specify?______________________________________________________________________________________

No

Prefer not to answer

5. Are you a current smoker (includes tobacco, e-cigarettes/vaping, or marijuana)?

Yes; answer Q49a

No; go to Q50

Prefer not to answer; go to Q50

49a. How long have you been smoking? ______________ years

5. Are you a former smoker (includes tobacco, e-cigarettes/vaping, marijuana)?

Yes; answer Q50a and Q50b

No; go to Q51

Prefer not to answer; go to Q51

50a. How long did you smoke? ______________ years

50b. How long since you quit smoking? ______________ years or months

5. Do you have any questions or additional details to share about the above patient care activities for COVID-19 patient(s)?

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