Online Survey Questionnaire (to be amended as appropriat

Form Approved

OMB Approval No. 0920-1154

Expiration Date: 03/31/2026

Online Survey Questionnaire (to be amended as appropriate following review of KII responses)

Intended Audience:

State Public Health Emergency Preparedness Directors (PHEP), with inputs from State Animal Health Officials (SAHO), State Public Health Veterinarians (SPHV) and other relevant staff

Definitions:

STLT: State, Tribal, Local and Territorial health departments

PPE: personal protective equipment

SNS: Strategic National Stockpile

Public reporting burden for this collection of information is estimated to be 120 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: CDC/ATSDR Reports Clearance Officer; Paperwork Reduction Project (0920-1154); MS H21-8; 1600 Clifton Road NE, Atlanta, Ga. 30333.

Survey Question	Response Options
Please select your jurisdiction from the list below.	Region 1 (CT, ME, MA, NH, RI, VT) Region 2 (NJ, NY, Puerto Rico, US Virgin Islands) Region 3 (DE, Washington DC, MD, PA, VA, WV) Region 4 (AL, FL, GA, KT, MS, NC, SC, TN) Region 5 (IL, IN, MI, MN, OH, WI) Region 6 (AR, LA, NM, OK, TX) Region 7 (IA, KS, MO, NE) Region 8 (CO, MT, ND, SD, UT, WY) Region 9 (AZ, CA, HI, NV USAPI*) Region 10 (AK, ID, OR, WA)
Did your jurisdiction have any confirmed cases of either human or animal cases of H5N1 at the time of the one-time PPE distribution activity on May 6, 2024?	Yes, both human and animal confirmed cases Yes, human confirmed cases Yes, animal confirmed cases No, neither human or animal confirmed cases I don’t know
Please select your role (select all that apply if completed by more than one person):	PHEP Director or co-Director State Epidemiologist State Animal Health Official (SAHO) State Public Health Veterinarian (SPHV) Other (please specify) ________________
Prior to the one-time personal protective equipment (PPE) ask made by CDC on May 6, 2024 (between April 1, 2024 to May 6, 2024), did your jurisdiction receive any requests for PPE from dairy farms, poultry farms, slaughterhouse workers, farmworker organizations, agricultural businesses, or related service organizations in the state that were impacted or could be potentially impacted by Avian Influenza A(H5N1)?	Yes No I don’t know
Prior to the one-time PPE ask made by CDC on May 6, 2024 (between April 1, 2024 to May 6, 2024), did your jurisdiction proactively offer PPE to dairy farms, poultry farms, slaughterhouse workers, farmworker organizations, agricultural businesses, or related service organizations in the state that were impacted or could be potentially impacted by Avian Influenza A(H5N1)?	Yes No I don’t know
After the one-time PPE ask made by CDC on May 6, 2024 (between May 7 to August 31, 2024), did your jurisdiction receive any requests for PPE from dairy farms, poultry farms, slaughterhouse workers, farmworker organizations, agricultural businesses, or related service organizations in the state impacted or potentially impacted by Avian Influenza A(H5N1)?	Yes No I don’t know
6a. If YES to receiving a request for PPE (question 6a), what type of entities made requests (select all that apply)?	Local health departments or local health entities Farms with known positives or presumptive positive dairy herds with Avian Influenza A(H5N1) Farms with known positive or presumptive positive poultry with Avian Influenza A(H5N1) Farms with no evidence of positive dairy herds or pending any test results Farms with no evidence of positive poultry or pending test results Other farm industry partners (please specify) ______ Non-farm related industry partner (please specify) ______ Slaughterhouse workers Other agricultural workers (please specify) ______ Unknown
After the one-time PPE ask made by CDC on May 6, 2024 (May 7 to August 31, 2024), did your jurisdiction proactively offer PPE to dairy farms, poultry farms, slaughterhouse workers, farmworker organizations, agricultural businesses, or related service organizations in the state that were impacted or could be potentially impacted by Avian Influenza A(H5N1)?	Yes No I don’t know
Was there a shortage of PPE during the month of May 2024 in your jurisdiction?	Yes No Do not know
8a. If YES to shortage of PPE (question 8), which supplies were temporarily unavailable or in limited supply (select all that apply)?	Fluid-resistant coveralls1 Waterproof apron NIOSH Approved® particulate respirator N95 or higher* Unvented or indirectly vented safety goggles2 Face shields­­ Head cover or hair cover Gloves3 Boots Other (please specify) _____________ Unknown * N95® and NIOSH Approved® are certification marks of the U.S. Department of Health and Human Services (HHS) registered in the United States and several international jurisdictions. 1 Preferably, fluid-resistant coveralls should be made of material that passes: AATCC 42 ≤ 1 g and AATCC 127 ≥ 50 cm H2O or EN 20811 ≥ 50 cm H2O; or ASTM F1670 (13.8 kPa); or ISO 16603 ≥ 3.5 kPA 2 Preferably, safety goggles should conform to ANSI Z87.1 that is marked at least Z87 D3 3 Preferably, gloves should conform to ASTM D3578 (latex rubber examination gloves), ASTM D5250 (vinyl examination gloves), ASTM D6319 (nitrile rubber examination gloves), or ASTM D6977 (chloroprene ­­examination gloves). If thicker gloves are required, rubber gloves should be waterproof and exclude linings. If latex allergies are present, avoid latex. These gloves could be worn underneath the exterior principal glove (e.g., gloves for cold protection, manual shoveling) for protection against direct skin exposure if the outer glove is physically compromised.
Do you have a stockpile of PPE in your jurisdiction (select all that apply)?	Yes, at least some local health departments have a stockpile Yes, all local health departments have a stockpile Yes, state health department has a stockpile Yes, both local health departments and state health departments have a stockpile Yes, tribal health departments have a stockpile Yes, both tribal health departments and state health departments have a stockpile Yes, all (state, tribal, local) health departments have a stockpile No, no stockpiles of PPE exist in my jurisdiction Unknown Other _____________
9a. If YES to stockpile(s) of PPE (question 9), which types of PPE are in stockpile(s) (select all that apply) in total?	Fluid-resistant coveralls In local health department stockpile In state health department stockpile In tribal health department stockpile Waterproof apron In local health department stockpile In state health department stockpile In tribal health department stockpile NIOSH Approved® particulate respirator N95 or higher* In local health department stockpile In state health department stockpile In tribal health department stockpile Unvented or indirectly vented safety goggles In local health department stockpile In state health department stockpile In tribal health department stockpile Face shields­­ In local health department stockpile In state health department stockpile In tribal health department stockpile Head cover or hair cover In local health department stockpile In state health department stockpile In tribal health department stockpile Gloves In local health department stockpile In state health department stockpile In tribal health department stockpile Boots In local health department stockpile In state health department stockpile In tribal health department stockpile Other (please specify) _____________ In local health department stockpile In state health department stockpile In tribal health department stockpile Unknown In local health department stockpile In state health department stockpile In tribal health department stockpile * N95® and NIOSH Approved® are certification marks of the U.S. Department of Health and Human Services (HHS) registered in the United States and several international jurisdictions. 1 Preferably, fluid-resistant coveralls should be made of material that passes: AATCC 42 ≤ 1 g and AATCC 127 ≥ 50 cm H2O or EN 20811 ≥ 50 cm H2O; or ASTM F1670 (13.8 kPa); or ISO 16603 ≥ 3.5 kPA 2 Preferably, safety goggles should conform to ANSI Z87.1 that is marked at least Z87 D3 3 Preferably, gloves should conform to ASTM D3578 (latex rubber examination gloves), ASTM D5250 (vinyl examination gloves), ASTM D6319 (nitrile rubber examination gloves), or ASTM D6977 (chloroprene ­­examination gloves). If thicker gloves are required, rubber gloves should be waterproof and exclude linings. If latex allergies are present, avoid latex. These gloves could be worn underneath the exterior principal glove (e.g., gloves for cold protection, manual shoveling) for protection against direct skin exposure if the outer glove is physically compromised.
9b. If YES to a stockpile of PPE (question 9a), has PPE been deployed from the STLT stockpile?	Yes No Unknown
Was PPE requested from the Strategic National Stockpile (SNS)?	Yes No, no PPE was requested Unknown
Are there plans to request PPE from the SNS?	Yes No Unknown
What type of PPE was requested on behalf of the end user from the one-time distribution of PPE request? Please select all that apply. (Make this a skip order logic if more than one organization requested)	Fluid-resistant coveralls Waterproof apron NIOSH Approved® particulate respirator N95 or higher* Unvented or indirectly vented safety goggles Face shields­­ Head cover or hair cover Gloves Boots Other (please specify) _____________ Unknown * N95® and NIOSH Approved® are certification marks of the U.S. Department of Health and Human Services (HHS) registered in the United States and several international jurisdictions. 1 Preferably, fluid-resistant coveralls should be made of material that passes: AATCC 42 ≤ 1 g and AATCC 127 ≥ 50 cm H2O or EN 20811 ≥ 50 cm H2O; or ASTM F1670 (13.8 kPa); or ISO 16603 ≥ 3.5 kPA 2 Preferably, safety goggles should conform to ANSI Z87.1 that is marked at least Z87 D3 3 Preferably, gloves should conform to ASTM D3578 (latex rubber examination gloves), ASTM D5250 (vinyl examination gloves), ASTM D6319 (nitrile rubber examination gloves), or ASTM D6977 (chloroprene ­­examination gloves). If thicker gloves are required, rubber gloves should be waterproof and exclude linings. If latex allergies are present, avoid latex. These gloves could be worn underneath the exterior principal glove (e.g., gloves for cold protection, manual shoveling) for protection against direct skin exposure if the outer glove is physically compromised.
Who were the key messengers to offer PPE to dairy farms, poultry farms, slaughterhouse workers, farmworker organizations, agricultural businesses, or related service organizations in the state? (e.g., state veterinarians, extension workers, community leaders, etc.) Select all that apply.	State Veterinarians State Public Health Veterinarians Local Veterinarians (or other veterinarians) Agriculture extension workers Community leaders Religious leaders Others (please specify) _________ Not applicable
Which options best describes the pathway or method of distributing PPE to dairy farms, poultry farms, slaughterhouse workers, farmworker organizations, agricultural businesses, or related service organizations in the state if applicable? Select all that apply.	Directly to farms/agricultural organizations (either dairy, poultry, or slaughterhouse) from state health department Directly to farm/agricultural organization employers (either dairy, poultry, or slaughterhouse) from local health department Directly to farm/agricultural organization employers (either dairy, poultry, or slaughterhouse) from a tribal health department Directly to farms/agricultural organizations employers from state agricultural associations (e.g., state dairy associations) Directly to farms/agricultural organizations from university extension agents Other (please specify) ______________ Unknown
Did you experience or observe any barriers related to PPE distribution? Select all that apply.	Workers were not interested in using PPE Operators were not interested in promoting the use of PPE Workers did not understand the risks of avian Influenza A(H5N1) infection Operators did not understand the risks of avian Influenza A(H5N1) infection Workers felt they were at a low risk of acquiring avian Influenza A(H5N1) given the nature of their job (e.g., did not work directly with milking cows) Operators felt workers were at a low risk of acquiring avian Influenza A(H5N1) given the nature of the workers’ job (e.g., did not work directly with milking cows) Issues or concerns with managing the heat/extreme temperatures and having to use PPE Respirator fit testing not available/not used Language barrier impeded messaging Workers’ lack of access to technology (ex: cell phones or computers) to receive messaging Workers not using social media where messages were shared Fear about legal status in the country Unknown Other ________________ If so, please explain.
Among the barriers listed above, which did you perceive to be the greatest barriers or most challenging to overcome? Select your top three.	Workers were not interested in using PPE Operators were not interested in promoting the use of PPE Workers did not understand the risks of avian Influenza A(H5N1) infection Operators did not understand the risks of avian Influenza A(H5N1) infection Workers felt they were at a low risk of acquiring avian Influenza A(H5N1) given the nature of their job (e.g., did not work directly with milking cows) Operators felt workers were at a low risk of acquiring avian Influenza A(H5N1) given the nature of the workers’ job (e.g., did not work directly with milking cows) Issues or concerns with managing the heat/extreme temperatures and having to use PPE Respirator fit testing not available/not used Language barrier impeded messaging Workers’ lack of access to technology (ex: cell phones or computers) to receive messaging Workers not using social media where messages were shared Fear about legal status in the country Unknown Other ________________ If so, please explain.
Did health departments promote PPE usage in response to requesting or receiving the one-time PPE distribution? (For example, this could be promotion via flyers or via social media)	Yes If yes, then please explain: __________________ No Do not know
Did agricultural partners promote PPE usage in response to requesting or receiving the one-time PPE distribution? (For example, this could be promotion via flyers or via social media)	Yes If yes, then please explain: __________________ No Do not know
Did dairy farm promote PPE usage in response to requesting or receiving the one-time PPE distribution? (For example, this could be promotion via flyers or via social media)	Yes If yes, then please explain: __________________ No Do not know
Did poultry farm promote PPE usage in response to requesting or receiving the one-time PPE distribution? (For example, this could be promotion via flyers or via social media)	Yes If yes, then please explain: __________________ No Do not know
Did slaughterhouse operators promote PPE usage in response to requesting or receiving the one-time PPE distribution? (For example, this could be promotion via flyers or via social media)	Yes If yes, then please explain: __________________ No Do not know
How beneficial was CDC’s recommendation to offer a one-time distribution of PPE to protect farmworkers from Avian Influenza A(H5N1)? Please select one option and explain your reasoning.	4- Very Beneficial Explain _________________ 3- Somewhat beneficial Explain _________________ 2- Neutral Explain _________________ 1- No benefit Explain _________________