0920-1296 Assessment of Healthcare Personnel Exposed to or Infecte

OMB: 0920-1296

Exp: 10/31/2020

Version: 07/17/2020

Assessment of Healthcare Personnel Exposed to or Infected with SARS-CoV-2:

Possible Reinfection Form

NEW EIP HCP ID: __________ FIRST 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 (EIP interviewer instructions)

1. Tell HCP to answer all questions on this form to the best of their knowledge.

2. For dates, tell HCP to use a calendar and any additional documentation or information they have available to help them remember and records dates as accurately as possible.

3. Record or calculate important reference dates below:

1. The date of initial interview for this project was: MM / DD / YYYY

2. The date of collection of the initial swab that tested positive for SARS-CoV-2 by PCR was:

MM / DD / YYYY

3. The symptom onset date of your initial SARS-CoV-2 infection was: MM / DD / YYYY or

No symptoms reported

D. The initial infection end date is: MM / DD / YYYY (the date of collection of the initial swab that tested positive for SARS-CoV-2 by PCR [B, above] + 60 days if HCP did NOT report any symptoms during the initial interview OR symptom onset date [C, above] + 60 days if HCP reported symptoms during the initial interview)

“Possible reinfection” definition:

A HCP case who has collection of a positive SARS-CoV-2 PCR test at least 60 days after the symptom onset date or (if symptoms were not reported) the first positive SARS-CoV-2 PCR test collection date of the prior infection during the project period.

5. On or after MM / DD / YYYY (insert initial infection end date), did you ever test positive for SARS-CoV-2 by PCR on a swab collected from your throat or nose?

Yes; go to Q7a

No; stop interview (NOT a reinfection)

Not sure; stop interview (NOT a reinfection)

7a. On or after MM / DD / YYYY (insert initial infection end date), when was the first swab collected that tested positive for SARS-CoV-2 by PCR?

MM / DD / YYYY (this is the possible reinfection date) Not sure

5. Did you have any symptoms in the 14 days before and on the possible reinfection date? MM / DD / YYYY to

MM / DD / YYYY

No; go to Q9

Yes; answer Q8a and Q8b.

8a. What symptoms did you have?

Felt feverish	Sore throat	Nausea or vomiting
Documented fever ≥100.0°F	Runny nose	Diarrhea
Chills	Shortness of breath	Abdominal pain
Dry cough	Muscle aches	Altered sense of smell or taste
Productive cough	Headache	Congestion
Fatigue or malaise	Chest pain/tightness	Loss of appetite
Other; specify: _____________________________________________

Other; specify: _____________________________________________

Other; specify: _____________________________________________

Other; specify: _____________________________________________

8b. What was the first date you started to have these symptoms? MM / DD / YYYY Not sure

INSTRUCTIONS FOR SECTIONS IV–VI

READ ME FIRST (EIP interviewer instructions)

1. Determine the “timeframe of interest” for answering Questions 9–33, as follows:

• If the HCP had symptoms reported in Q8a, the timeframe of interest is defined by the 14 days before and on the day of symptom onset reported in Q8b (MM / DD / YYYY to MM / DD / YYYY)

• If the HCP did NOT report symptoms in Q8a, the timeframe of interest is defined by the 14 days before and on the possible reinfection date reported in question 7a above (MM / DD / YYYY to MM / DD / YYYY)

2. Review the following definitions:

• A person with suspected COVID-19 is someone who has symptoms consistent with COVID-19 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; 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 DURING TIMEFRAME OF INTEREST

(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

worked during the timeframe of interest?

Yes; answer Q9a and Q9b

No; go to Q10

Not sure; go to Q10

9a. 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? ________________________________________________________

9b. 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 any of the following situations apply to you during the timeframe of interest? (Check all that apply)

Attended a gathering that included people other than your household members (such as a religious event, wedding, party, sports event)

Used public transportation (for example, a bus, train, airplane)

Used shared transportation (such as a car or van pool, ride share service)

Had close contact with a child who attended school or daycare

Traveled overnight domestically or internationally

Other; can you specify? ____________________________________________________________________________________________

None of these apply

5. HCP EXPOSURES AND PATIENT CARE ACTIVITIES DURING WORK IN HEALTHCARE FACILITY DURING TIMEFRAME OF INTEREST (MM / DD / YYYY to MM / DD / YYYY)

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

5. Did your healthcare personnel role(s) change since the initial interview?

No; go to Q12

Yes; answer Q11a

11a. 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. Did the type of healthcare facility where you work change since the initial interview?

No; go to Q13

Yes; answer Q12a

12a. What type of healthcare facility(ies) do you work in now? (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? _________________________________________________________________

5. Do you work in a different area(s) in the facility (e.g., ICU, Emergency Room, etc.) than at the time of your initial interview?

No; go to question 14

Yes; answer question 13a

13a. In which area(s) of the facility(ies) do you normally work now? (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

14. 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

15. 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

16. Did you have any close contacts with COVID-19 patient(s) during work in your facility during the timeframe of interest?

Yes

No; go to Q32

Not sure; go to Q32

17. 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

17. 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? __________________________ _________________________________________________________

18. 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

17. Did you wear any alternative or improvised equipment to protect yourself during care of COVID-19 patients?

No; go to Q21

Yes; answer Q20a

20a. 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? ______________________________________________________________________________________

6. HCP PARTICIPATION IN AEROSOL-GENERATING PROCEDURES DURING WORK IN HEALTHCARE FACILITY DURING TIMEFRAME OF INTEREST (MM / DD / YYYY to MM / DD / YYYY)

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

17. Did you participate (i.e., perform/assist or present in room) in any aerosol-generating procedures (AGPs) for COVID-19 patient(s)? (Refer to examples of AGPs above)

Yes; answer Q21a

No; go to Q22

Not sure; go to Q22

20a. Which of the following 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

17. 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

17. 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

23a. 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

17. 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

17. 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

17. 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 for 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? _____________________________________________________________________________________

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

Yes – during the past year; answer Q27a

Yes – more than one year ago; answer Q27a

No; go to Q28

Not sure; go to Q28

27a. 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

17. Did you have any exposures of your mucous membranes (for example, your mouth or eyes) or skin to COVID-19 patients’ 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

17. Did you have any percutaneous exposures (e.g., needle sticks or cuts) to COVID-19 patients’ 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

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

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

All the time Most of the time Sometimes Rarely or never

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

All the time Most of the time Sometimes Rarely or never

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

All the time Most of the time Sometimes Rarely or never

7. ADDITIONAL INFORMATION

17. 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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