Risk assessment and management of exposure of health care workers in the context of COVID-19
1. Interviewer information
A. Interviewer Nmae
First Name
Last Name
B. Interview date (DD/MM/YYYY)
/
Month
/
Day
Year
Date
C. Interviewer phone number:
D. Does the HCW have a history of staying in the same household or classroom environment with a confirmed COVID-19 patient?
Yes
No
E. Does the HCW have history of traveling together in close proximity (within 1 meter) with a confirmed COVID-19 patient in any kind of conveyance?
Yes
No
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2. Health worker information
Name
B. First name
A. Last name
C. Age
D. Sex
Male
Female
Prefer not to answer
E. City:
F. Country:
G. Contact details (phone number):
H. Type of health care personnel:
Medical Doctor
Registered Nurse
Assistant Nurse
Radiology Technician
Laboratory Personnel
Phlebotomist
Nutritionist/Dietition
Pharmacist
Admission/Reception Personnel
Porter
Cleaner
Other
I. Type of health care facility (Tick all that apply:)
Outpatient
Emergency
Medical Surgical Ward
Intensive care unit
Cleaning services
Laboratory
Pharmacy
Other, specify:
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3. Health worker interaction with COVID-19 patient information
A. Date of health worker first exposure to confirmed COVID 19 patient:
/
Month
/
Day
Year
Date
B. Name of health care facility where patient received care:
C. Type of health care setting:
D. City:
E. Country:
F. Multiple COVID-19 patients in health care facility
Yes
No
Unknown
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4. HCW activities performed on COVID-19 patient in health care facility
A. Did you provide direct care to a confirmed COVID-19 patient?
Yes
No
Unknown
B. Did you have face-to-face contact (within 1 meter) with a confirmed COVID-19 patient in a health care facility?
Yes
No
Unknown
C. Were you present when any aerosol-generating procedures were performed on the patient? e.g. Tracheal intubation, Nebulizer treatment, Open airway suctioning, Collection of sputum, Tracheotomy, Bronchoscopy , Cardiopulmonary resuscitation (CPR)
Yes
No
Unknown
D. Did you have direct contact with the environment where the confirmed COVID-19 patient was cared for? E.g. bed, linen, medical equipment, bathroom etc
Yes
No
Unknown
E. Were you involved in health care interaction(s) (paid or unpaid) in another health care facility during the period above?
Yes
No
Unknown
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5. Adherence to IPC procedures during health care interactions
For the following questions, please quantify the frequency with which you wore PPE while coming in contact with patient, as recommended: ‘Always, as recommended’ means more than 95% of the time; ‘Most of the time’ means 50% or more but not 100%; ‘occasionally’ means 20% to under 50% and ‘Rarely’ means less than 20%.
A. During a health care interaction with a COVID-19 patient, did you wear personal protective equipment (PPE)?
Yes
No
1. Single use gloves
Always, as recommended
Most of the time
Occasionally
Rarely
2. Medical mask
Always, as recommended
Most of the time
Occasionally
Rarely
3. Face shield or goggles/protective glasses
Always, as recommended
Most of the time
Occasionally
Rarely
4. Disposable gown.
Always, as recommended
Most of the time
Occasionally
Rarely
B. During a health care interaction with the COVID-19 patient, did you remove and replace your PPE according to protocol (e.g. when medical mask became wet, disposed the wet PPE in the waste bin, performed hand hygiene, etc.)?
Always, as recommended
Most of the time
Occasionally
Rarely
C. During a health care interaction with the COVID-19 patient, did you perform hand hygiene before and after touching the COVID-19 patient (whether or not you were wearing gloves)?
Always, as recommended
Most of the time
Occasionally
Rarely
D. During a health care interaction with the COVID-19 patient, did you perform hand hygiene before and after any clean or aseptic procedure was performed (e.g. while inserting a peripheral vascular catheter, urinary catheter, intubation, etc.)?
Always, as recommended
Most of the time
Occasionally
Rarely
E. During a health care interaction with the COVID-19 patient, did you perform hand hygiene after exposure to body fluid?
Always, as recommended
Most of the time
Occasionally
Rarely
F. During a health care interaction with the COVID-19 patient, did you perform hand hygiene after touching the patient’s surroundings (bed, door handle, etc.), regardless of whether you were wearing gloves?
Always, as recommended
Most of the time
Occasionally
Rarely
G. During a health care interaction with the COVID-19 patient, were high-touch surfaces decontaminated frequently (at least three times daily)?
Always, as recommended
Most of the time
Occasionally
Rarely
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6. HCW aerosol-generating activities performed on COVID-19 patient in health care facility
A. Have you performed/were attending aerosol-generating procedures (e.g. tracheal intubation, nebulizer treatment, open airway suctioning, collection of sputum, tracheotomy, bronchoscopy, cardiopulmonary resuscitation (CPR), etc.).
Yes
No
7. Adherence to IPC measures when performing aerosol-generating procedures (e.g. tracheal intubation, nebulizer treatment, open airway suctioning, collection of sputum, tracheotomy, bronchoscopy, cardiopulmonary resuscitation (CPR), etc.).
For the following questions, please quantify the frequency with which you wore PPE while coming in contact with patient, as recommended: ‘Always, as recommended’ means more than 95% of the time; ‘Most of the time’ means 50% or more but not 100%; ‘occasionally’ means 20% to under 50% and ‘Rarely’ means less than 20%.
A. During aerosol-generating procedures on a COVID-19 patient, did you wear personal protective equipment (PPE)?
Yes
No
1. Single use gloves
Always, as recommended
Most of the time
Occasionally
Rarely
2. N95 mask
Always, as recommended
Most of the time
Occasionally
Rarely
3. Face shield or googles/Protective glasses
Always, as recommended
Most of the time
Occasionally
Rarely
4. Disposable gown
Always, as recommended
Most of the time
Occasionally
Rarely
5. Waterproof apron
Always, as recommended
Most of the time
Occasionally
Rarely
B. During aerosol-generating procedures on the COVID-19 patient, did you remove and replace your PPE according to protocol e.g. when medical mask became wet, disposed the wet PPE in the waste bin, performed hand hygiene, etc?
Always, as recommended
Most of the time
Occasionally
Rarely
C. During aerosol-generating procedures on the COVID-19 patient, did you perform hand hygiene before and after touching the COVID-19 patient, regardless of whether you were wearing gloves?
Always, as recommended
Most of the time
Occasionally
Rarely
D. During aerosol-generating procedures on the COVID-19 patient, did you perform hand hygiene before and after any clean or aseptic procedure was performed?
Always, as recommended
Most of the time
Occasionally
Rarely
E. During aerosol-generating procedures on the COVID-19 patient, did you perform hand hygiene after touching the patient’s surroundings (bed, door handle, etc), regardless of whether you were wearing gloves?
Always, as recommended
Most of the time
Occasionally
Rarely
F. During aerosol-generating procedures on the COVID-19 patient, were high-touch surfaces decontaminated frequently (at least three times daily)?
Always, as recommended
Most of the time
Occasionally
Rarely
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8. Accidents with biological material
A. During a health care interaction with a COVID-19 patient, did you have any type of accident with body fluid/respiratory secretions? See below for examples
Yes
No
if yes, which type of accident?
Splash of biological fluid/respiratory secretions in the mucous membrane of eyes
Splash of biological fluid/respiratory secretions in the mucous membrane of mouth/nose
Splash of biological fluid/respiratory secretions on non-intact skin
Puncture/sharp accident with any material contaminated with biological fluid/respiratory secretions
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