Form 0920-1033 Att A HCW.EVD.expriskreport_WestAfrica

Form Approved
OMB No. 0920-1033
Exp. Date 04/30/2015

Health-care workers (HCWs) and Ebola Virus Disease (EVD) exposure risk:
Reporting form to be completed for EVD cases in HCWs in West Africa
Case ID Number..........................................

1. PATIENT (HCW) IDENTITY
Last name:........................................... First Name:........................................... Second Name:...........................................
Nickname:.............................................
Date of birth:.........../.........../...........(dd/mm/yy)
Age (years):...............
Sex:
M
F
Village/neighbourhood of residence:...................................../........................................ District:........................................
GPS coordinates of domicile: Latitude:........................................................ Longitude:.......................................................
Ordinary residence: Head of household (last and first name):................................................................................................
Full address (if known):.......................................................................................................................................................
Nationality:........................................................................ Ethnic group:...........................................................................
Case classification
Suspected
Confirmed

2. PATIENT’S OCCUPATION (tick the appropriate box and provide details if/when necessary)
Doctor
Nurse
Office staff
Laboratory staff
Cleaner
Morgue/burial staff
Midwife
Ambulance driver
Traditional healer
Community health worker
Other (specify):
.........................................................................................................................................................................................
Health-care facility (HCF) name:.....................................................................................
Primary work place at the time of infection:
Ebola Treatment Center
Outpatient setting
Service:

Ebola Care Unit
Laboratory

Public hospital

Other (specify):.............................................................................................

EVD Suspected Cases Unit
Maternity

“Transit”/“Holding” center

Laboratory

Blood Transfusion

EVD Confirmed Cases Unit
Medicine

Administration

General Care Unit

Paediatric
Morgue

Surgery

Emergencies

Other (specify):..................................

Additional work place (paid or voluntary) at the time of infection:
Ebola Treatment Center
Outpatient setting
Service:

Ebola Care Unit
Laboratory

Public hospital

Other (specify):.............................................................

EVD Suspected Cases Unit
Maternity

“Transit”/“Holding” center

Laboratory

Blood Transfusion

EVD Confirmed Cases Unit
Medicine

Administration

General Care Unit

Paediatric
Morgue

Surgery

Emergencies

Other (specify):..................................

None
Activities that may have led to exposure (tick all that apply):
Provided general patient care (took vital signs, examined patients, moved patients)
Fed patients or administered oral medications
Bathed or cleaned patients
Gave injections

Drew blood

Discarded sharps
Put in IV

Moved/transported patients
Performed fingerprick

Cleaned needle for re-use

Handled IV line (e.g., gave IV medications)

Cleaned blood spill
Handled lab specimens

Recapped needle

Cleaned patient room or ward
Controlled bleeding

Handled urinary catheter
Handled waste

Had contact with contaminated surfaces

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Delivered babies
Public reporting burden of this collection of information is estimated to average 30 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 Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-1033).

Case ID Number..........................................
Performed invasive procedure
Performed minor surgery
Performed major surgery
Moved dead bodies
Performed autopsy
Cleaned or disinfected latrines
Handled linen or clothes or mattresses (cleaners)
Provided care to sick relatives or significant others
Other: (specify)............................................................................................................................................................

3. CONTACT WITH EVD PATIENT(S):
Has the HCW been in contact* with anyone who had suspected or confirmed EVD in the 3 weeks preceding
onset of symptoms?
Yes
No
Don’t know
If Yes, was the contact a (if multiple contacts, indicate ‘confirmed’ if at least one contact was a confirmed EVD case):
Suspected EVD case
Confirmed EVD case
If Yes, where (tick all that apply):
in an Ebola Treatment Center
in a private clinic/cabinet

Ebola Care Unit
in another HCF
at home
in the community

If Yes, specify relationship with HCW (tick all that apply):
Patient
Other HCW
Household member
Other friend or relative
None
If other HCW included in previous response, did the contact occur:
At work, in a patient care area
At work, in a non-patient care area (break room, office, nursing station, etc)
Outside work
Did the HCW attend the funeral of someone who might have died of Ebola in the 3 weeks preceding
the onset of symptoms?
Yes
No
If Yes, did the HCW participate in the preparation of burials involving touching the dead body,
with no adequate personal protective equipment (PPE)**?
Yes
No
If Yes, did the HCW provide care to any suspected Ebola patients in a private home (not in a HCF)?
Yes
No

4. MOST LIKELY EXPOSURE TO EVD
Did the HCW describe any single exposure situation that most likely led to infection?
If Yes, skip the next three questions and go to section 5
If No, specify the date:.........../.........../...........(dd/mm/yy)

Yes

No

Don’t know

Setting where suspected exposure occurred:
Ebola Treatment Center
Outpatient setting
Home

Ebola Care Unit
Laboratory

“Transit”/“Holding” center

Public hospital

Other type of HCF (specify):...............................................

Other community setting (specify):......................................................................................

Mode of exposure:
Needle stick

Scalpel cut

Blood/body fluid splash on eye

Blood/body fluid splash on intact skin

Blood/body fluid splash on non-intact skin

Blood/body fluid splash on mouth/lips

Other (specify)....................................

Contaminant:
Blood

Any body fluid with visible blood

Vomit or saliva

Faeces

Urine

Internal body fluids (circle which one [s]): cerebrospinal, synovial, pleural, amniotic, pericardial, peritoneal
Vaginal secretions

Seminal fluid

Other (specify):...................................................................

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Case ID Number..........................................

5. INFECTION PREVENTION AND CONTROL ASPECTS OF PRIMARY WORK PLACE
Use of PPE and Standard Precautions:
At time of exposure, was any PPE used?
If Yes, which ones (tick all that apply):
Coverall (Tyvek-like)
Goggles
Cap

Yes

No
Single gloves

Face shield

Face mask

Waterproof apron
Hood

Don’t know
Double gloves

N-95 respirator or above

Closed resistant shoes

Leg covers

Yes

No

Gum boots

Don’t know

Were hand hygiene products available at the time of exposure
Yes
If Yes, which ones (tick all that apply):
Running (tap) water
Disposable towels

Shoe covers

Other (specify):......................................

Did the HCW apply duct tape to secure your PPE

Soap

Disposable gown

No
Don’t know
Chlorinated water from reservoir

Alcohol antiseptic

Was hand hygiene performed appropriately***?

Yes

At time of exposure, were safety boxes available?

No

Yes

Don’t know

No

Don’t know

On average, how many hours did you work while wearing PPE** in the isolation area?.....................................................
Have you been trained on infection prevention and control in the context of the Ebola outbreak?

Yes

No

Which organization led this training?
National Government

WHO

CDC

MSF

Other (specify):...................................................................................

UNMEER
Don’t know

*

Contact defined as the HCW touching, without proper personal protective equipment (PPE), a suspect or confirmed EVD
patient or their bodily fluids.
** PPE= gloves, impermeable gown or coverall, impermeable head cover with neck protection, rubber boots, face mask and
face shield or goggles.
*** Appropriate hand hygiene indications: before donning gloves and wearing PPE; before any clean/aseptic procedures; after
any exposure risk or actual exposure to the patient’s blood and body fluids; after touching (even potentially) contaminated
surfaces/items/equipment; after removal of PPE, upon leaving the care area.

Additional details of exposure or comments:....................................................................................................................
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© The World Health Organization, 2014. All rights reserved.
WHO/EVD/caserep/14