0920-1296 Assessment of Healthcare Personnel Exposed to or Infecte

OMB: 0920-1296

Exp: 10/31/2020

Version: 07/17/2020

A ssessment of Healthcare Personnel

Exposed to or Infected with SARS-CoV-2

EIP HCP ID: ________________ COVID-NET ID: ________________ CDC/STATE CASE ID: ________________

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.

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.

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

Yes

No; STOP the interview

Not sure; STOP the interview

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

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; go to 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

11c. 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 15 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 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 where 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 and 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 and 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
Fatigue or malaise	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
Chest pain/tightness	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
Congestion	MM / DD / YYYY Not sure	MM / DD / YYYY Not sure
Loss of appetite	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

INSTRUCTIONS FOR SECTIONS IV–VI

READ ME FIRST (EIP interviewer instructions)

1. If the HCP was diagnosed with COVID-19 and had symptoms, complete Questions #15–40 with information for the 14 days before and the day of symptom onset (MM / DD / YYYY to MM / DD / YYYY)

2. If the HCP was diagnosed with COVID-19 and did NOT have symptoms, complete Questions #15–40 with information for the 14 days before and on the specimen collection date of the first positive coronavirus test

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

3. If the HCP was NOT diagnosed with COVID-19 and had symptoms, complete Questions #15–40 with information for the14 days before and the day of symptom onset (MM / DD / YYYY to MM / DD / YYYY)

4. If the HCP was NOT diagnosed with COVID-19 and did NOT have symptoms, complete Questions #15–40 with information for the 14 days before and on the specimen collection date of the most recent NEGATIVE coronavirus test result (MM / DD / YYYY to MM / DD / YYYY)

REMINDER: 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; 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).

4. HCP COMMUNITY EXPOSURES

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 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 Daycare School/University Transit Rideshare Hotel

Cruise ship Healthcare facility (non-work reasons) Other; can you specify? ________________________

5. Did you travel away from home? (Check “Yes” if your return date is between MM / DD / YYYY and MM / DD / YYYY as 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 gathering that included people other than your household members (such as a religious event, wedding, party, 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

(Remember to refer to the timeframe defined in the INSTRUCTIONS FOR SECTIONS IV–VI above)

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

Administrative staff	Licensed practical nurse	Physician assistant
Chaplain	Medical assistant	Physician (intern/resident)
Environmental services worker	Nurse practitioner	Physician (fellow)
Facilities/maintenance worker	Nursing assistant	Respiratory therapist
Food services worker	Nutritionist	Registered nurse
Home health aide/caregiver	Occupational therapist	Social worker
Laboratory personnel	Pharmacist or pharmacy personnel	Speech therapist
Cytotechnologist	Phlebotomist	Student
Histotechnologist	Physician (attending)	Ward clerk
Medical/clinical lab scientist	Physical therapist
Medical laboratory technician	Other; can you specify?
PhD laboratory scientist
Other laboratory personnel

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)

Administrative offices	Laboratory	Pharmacy
Dining room or cafeteria	Clinical pathology	Private residence (home health)
Emergency room/department	Anatomic pathology	Radiology department
Endoscopy room	Other laboratory type	Reception area
Inpatient ward	Nursing home ward	Other; can you specify? _____________
Intensive care unit	Operating room	____________________________________________
Kitchen	Outpatient clinic area

20a. Did you telework or work remotely from a location that is not a healthcare facility (such as from home)?

All the time

Some of the time

Not at all

Not sure

20b. Did you have close contact with someone with COVID-19 who was not a patient during work in your facility? (Check all that apply)

Coworker with COVID-19 Visitor with COVID-19

Someone else (NOT a patient) with COVID-19; can you specify? ________________________________________

No

Not sure

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

Yes

No; go to Q39

Not sure; go to Q39

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

Dining room or cafeteria	Nursing home common area
During transport	Nursing home resident room
Emergency room examination room	Operating room
Endoscopy room	Outpatient examination room
Inpatient ward patient room	Other; can you specify? _____________________________
Intensive care unit patient room	Private residence (home health)
Laboratory	Radiology department
Not sure	Reception area

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

   Arterial blood gas collection	Insertion of peripheral line
   Bathing	Lifting or positioning
   Changing linen	Manipulation of oxygen face mask or tubing
   Chest tube (insert or remove)	Manipulation of ventilator or tubing
   Cleaning the room	Participating in surgery
   Collecting respiratory specimens	Performing oral care (such as tooth brushing)
   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
   Insertion of nasogastric tube	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)

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/face shield	All the time	Most of the time	Sometimes	Rarely or never

5. Did you wear any alternative or improvised equipment during care of COVID-19 patients?

Yes; answer Q25a

No; go to Q26

Not sure; go to Q26

25a. If yes, what alternative or improvised equipment did you wear? (Check all that apply)

Face covering that was not a medical mask or respirator, such as a cloth face covering, bandana, balaclava

A covering for clothing other than a medical gown, such as a lab coat, trash bag, or raincoat

Improvised eye protection, such as a homemade face shield

Other; can you specify? _____________________________________________________________________________________

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

______________________________________

______________________________________

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

(Remember to refer to the timeframe defined in the INSTRUCTIONS FOR SECTIONS IV–VI above)

READ ME FIRST (EIP interviewer instructions)

For this section, refer to these examples of aerosol-generating procedures (AGPs):

• 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)

• Sputum induction

• Certain dental procedures

• Other aerosol generating procedures

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

Yes; answer Q26a

No; go to Q27

Not sure; go to Q27

26a. 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

Procedure

PPE Frequency of use

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

Procedure

PPE Frequency of use

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

Number of procedures: _____________________

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

Other AGP; can you specify? _________________________

Performed or assisted Present in room

Number of procedures: _____________________

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

Other AGP; can you specify? _________________________

Performed or assisted Present in room

Number of procedures: _____________________

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 you were 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 cloth face covering 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

30a. Which of the following was in place on COVID-19 patient(s) during your contacts? (Check all that apply)

Surgical or procedure mask Cloth face covering N95 respirator

Endotracheal or nasotracheal tube (for invasive mechanical ventilation)

Other; can you specify? _____________________________________________________________________________________

None

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 use any of the following practices when wearing an N95 respirator? (Check all that apply)

I wore one N95 respirator for repeated close contact encounters with several patients, without removing the respirator between patient encounters.

I wore one N95 respirator for repeated close contact encounters with several patients, but I usually removed it (‘doffed’) after each encounter.

I wore the same N95 respirator on multiple workdays.         

I wore a respirator, but I did not use any of these practices.

I did not use a respirator.

Other; can you specify? _____________________________________________________________________________________

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

Yes – during the past year; answer Q34a

Yes – more than one year ago; answer Q34a

No; go to Q35

Not sure; go to Q35

34a. During the timeframe of interest, were you able to wear the respirator that you were fit tested for while caring for COVID-19 patients?

Yes No Not sure Did not use a respirator

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 DEMOGRAPHICS AND UNDERLYING MEDICAL CONDITIONS

5. What sex were you assigned at birth, on your original birth certificate?

Male Female Refused I don’t know

41a. Do you currently describe yourself as male, female, or transgender?

Male Female Transgender None of these

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

READ ME FIRST: Questions 45 and 46 ask about your race and ethnicity based on federal government reporting standards.

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

Hispanic or Latino Not Hispanic or Latino

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

American Indian or Alaska Native	White
Asian
Black or African American
Native Hawaiian/other Pacific Islander

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 Q50a

No; go to Q51

Prefer not to answer; go to Q51

50a. How long have you been smoking? ______________ years

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

Yes; answer Q51a and Q51b

No; go to Q52

Prefer not to answer; go to Q52

51a. How long did you smoke? ______________ years

51b. How long since you quit smoking? ______________ years or months

5. When was the last time you received flu vaccine? MM/YYYY    Not sure

Never received flu vaccine    

8. ADDITIONAL INFORMATION

5. Do you have any additional information you would like to share?

Public reporting burden of this collection of information is estimated to average 32 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 Information Collection Request Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30329; ATTN: PRA (0920-1296).

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