57.204_HCWDemographicData_BLANK

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Healthcare Worker Demographic Data
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*required for saving
Facility ID#:
*HCW ID#:
Social Security #:
Secondary ID#:
HSW Name, Last:
First:
Middle:
Street Address:
City:
Sate:
Zip Code:
Home Phone: (       )
Email Address:
*Gender: □ F    □ M     □ Other
*Date of Birth: _____ /_____ /______
Born in U.S.?  □ Yes    □ No     □ Unknown
Ethnicity:   □ Hispanic or Latino
Race: □ American Indian or Alaskan Native
 □ Not Hispanic or Not Latino
□ Asian

□ Black or African American

□ Native Hawaiian or Other Pacific Islander

□ White
Employment Information
Work Phone: (       )
*Start Date: _____ /_____ /______
*Work Status: □ Active      □ Inactive      □ No longer affiliated
*Type of employee: □ Full-time   □ Part-time   □ Contract employee   □ Volunteer    □ Other (specify)_________
*Work Location:
Department:
Supervisor:
*Occupation:
Title:
If occupation is physician, indicate clinical specialty (check one):
□ ANE – Anesthesiology
□ NRS – Neurosurgery
□ CAR – Cardiology
□ OBG – Obstetrics and Gynecology
□ CTS – Cardiothoracic Surgery
□ OPT – Ophthalmology
□ CRC – Critical Care
□ ORT – Orthopedics
□ DOS – Dentistry/Oral Surgery
□ OSS – Other Surgical Specialty
□ DER – Dermatology
□ OTH – Other Clinical Specialty
□ ENT – Ear, Nose and Throat
□ PAT – Pathology
□ ERM – Emergency Medicine
□ PED – Pediatrics
□ FAP – Family Practice
□ PLS – Plastic Surgery
□ GAS – Gastroenterology
□ PMR – Physical Medicine/Rehab
□ GEN – General Surgery/Trauma
□ PSC – Psychiatry
□ IND – Infectious Diseases
□ PUL – Pulmonology
□ INM – Internal Medicine
□ RAD – Radiology
□ MSU – Other Medical Subspecialty
□ URO – Urology
□ NEP – Nephrology
□ VAS – Vascular Surgery
□ NEU – Neurology

Performs direct patient care (i.e., hands on, face-to-face contact with patients for the purpose of diagnosis, treatment and/or monitoring):
□ Yes
□ No

Assurance of Confidentiality:  The voluntarily provided information obtained in this surveillance system that would permit identification of any individual or institution is collected with a guarantee that it will be held in strict confidence, will be used only for the purposes stated, and will not otherwise be disclosed or released without the consent of the individual, or the institution in accordance with Sections 304, 306 and 308(d) of the Public Health Service Act (42 USC 242b, 242k, and 242m(d)).
Public reporting burden of this collection of information is estimated to average 20 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, Reports Clearance Officer, 1600 Clifton Rd., MS D-74, Atlanta, GA 30333,  ATTN:  PRA (0920-0666).
CDC 57.204 (Front), v6.6
Healthcare Worker Demographic Data
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