Form 0920-1033 Att C HCW.Ebola.virus.invest.questionnaire_Liberia

Case ID number: ______________________

Health care worker Ebola virus investigation
questionnaire
Liberia

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

(last edit 3 Dec 2014)

1. Introduction
Hi, my name is ____ and I’m working with the MOHSW. We would like to talk to you to try to
find out how you may have got infected. The reason we want to know is to try to stop other health
workers getting sick. Is it ok to ask you a few questions about how you may have got sick?
If you feel tired at any point please let me know and we can let you rest.
It is ok if you don’t remember any details, just let us know.
The information we collect is confidential. Any analysis conducted will not contain your name.
Lastly, do you consent to us contacting your family and some of your colleagues to help answer some
of these questions? Who would be the best people to talk to? _______________________________
How do we contact them: _____________________________________________________________

☐Yes ☐No (specify reason):________________________________

Verbal consent obtained:

2. Interview details (interviewer)
Investigator name: ____________________________Investigation date (dd/mm/yy):___/___/____
Interviewed:
Patient
Other person1- specify name:__________________________________________
Relationship to patient: _______________________________________________
Contact phone number:_______________________________________________
Address of person interviewed: _________________________________________
__________________________________________________________________
Other person2- specify name:__________________________________________
Relationship to patient: _______________________________________________
Contact phone number:_______________________________________________
Address of person interviewed: _________________________________________
__________________________________________________________________
Other person3- specify name:__________________________________________
Relationship to patient: _______________________________________________
Contact phone number:_______________________________________________
Address of person interviewed: _________________________________________
__________________________________________________________________

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3. HCW identity (HCW or administration)
Surname name:______________ First name:__________________ Second name:________________
Nickname/alternate name: ________________________________
Date of birth (dd/mm/yy): ____/____/____ Age (years):_________
Sex:
Male
Female
Permanent residence: ________________________________________County:__________________
Health District: ___________________Clan/Zone: _________________Country:__________________
Next of kin (last and first name):________________________________Phone:___________________
Full address (if known):________________________________________________________________
Nationality: ____________________________ Ethnic group:_________________________________
Religion:
Christian
Islam
Traditional
No religion
Unknown
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Other (specify):____________________________________________________________

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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: ______________________

4. HCW status

(administration)

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Was HCW tested for Ebola?
Yes
No
Don’t know
If Yes, was the Ebola test positive?
Yes
No
Don’t know
HCW classification:
Suspected
Probable
Confirmed
Alive
Dead
Don’t know
Status
If alive:
Well for interview
Too unwell for interview
Date of onset: ___/___/_____ Calculated incubation period (21 days prior):____________________

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5. Work details (HCW, colleague, family)

☐ Doctor ☐ Physician Assistant ☐ Nurse ☐ Nurse Aid
☐ Lab technician
☐ Midwife ☐Trained traditional midwife
☐ Cleaner (hygienist) ☐ Office
☐ Mortician ☐ Security guard ☐Vaccinator ☐ Ambulance driver ☐ Traditional healer
☐ Community health worker
☐Pharmacist ☐Private drug store worker
☐Other (specify):_____________________________________________________________________
Healthcare facility (HCF) workplace 21 days prior to illness onset: (tick all that apply):

☐ Ebola Treatment Unit (ETU) ☐ Community Care Center (CCC) ☐Hospital ☐ Health centre
☐ Laboratory
☐Clinic
☐Pharmacy/medicine store
☐ Other (specify):_________________________________________________________________
Service area/s: ☐ EVD Suspected Cases Unit
☐ EVD Confirmed Cases Unit ☐Ebola contacts
☐ OPD
☐ IPD
☐ Maternity ☐ Laboratory
☐ Pharmacy
☐ Paediatric ☐ Surgery ☐ Emergency ☐ Triage
☐Administration
☐ Morgue ☐ Ambulance ☐ Other (specify):_________________________________________

HCF name and location 1: _____________________________________________________________
HCF name and location 2: ______________________________________________________________
HCF name and location 3: ______________________________________________________________

6. IPC training (HCW)
Did HCW receive training on infection prevention and control in the context of the Ebola outbreak?
Yes, specify date of the training?: ___/____
No
Don’t know

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How long did the training last?

☐ Less than 1 day

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☐ 1 day

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☐ More than 1 day

At any time in their training did HCW practice putting on and taking off all or any items of PPE?
Yes
No
Don’t know

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At any time in their training did HCW practice correct hand washing procedure?
Yes
No
Don’t know

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Case ID number: ______________________

7. Contact with EVD patient/s (HCW, colleague, family)
COMMUNITY: Had the HCW been in known direct contact COMMUNITY with anyone with suspected,
No
Don’t know
probable, or confirmed EVD in the 21 days prior to illness onset? Yes

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Was the contact with:
Was the contact:
Type of exposure

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Located:
(tick all that apply)

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☐ Don’t know

☐ Suspected ☐ Probable ☐Confirmed
☐ Protected ☐ Unprotected
☐Intimate contact ☐Sharing of utensils
☐Caring for sick
☐Other (specify): ________________________________________________

Specify EVD patient’s relationship with HCW (tick all that apply):
Patient
Household member
Friend
Other (specify): __________________________________________

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☐ Relative

☐ None

☐ At home (specify):_______________________________________________
☐In the community (specify):_______________________________________

Did the HCW attend any funeral of someone who might have died of Ebola in the 3 weeks preceding
the onset of the symptoms?
Yes
No
Don’t know

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If yes, did the HCW participate in the preparation of burials that involved touching the dead body
without adequate PPE?
Yes
No
Don’t know

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WORK: Had the HCW been in known direct contact AT WORK with anyone with suspected, probable,
or confirmed EVD in the 21 days prior to illness onset?
Yes
No
Don’t know

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If Yes to either: (tick all that apply and indicate healthcare facility)
Was the contact:
Type of exposure:

Located:
(tick all that apply)

☐ Protected ☐ Unprotected
☐Needle stick ☐Scalpel cut
☐Body fluid splash on intact skin ☐Body fluid splash on non-intact skin
☐Body fluid splash on eye
☐Body fluid splash on mouth/lips
☐ Other (specify): ________________________________________________
☐Ebola Treatment Unit (ETU) (specify):________________________________
☐ Community Care Center (CCC) (specify):_____________________________
☐ Another health care facility (specify):________________________________

Specify EVD patient’s relationship with HCW (tick all that apply):
Patient
Other HCW (specify below)
Other (specify): _____________________

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If “Other HCW” was contact:

☐ At work, in a patient care area (specify facility): ______________________________________
☐ Outside of workplace (specify facility): ______________________________________________
☐ At work, in a non-patient care area (break room, office, nursing station, etc) (specify): _______

Why did unprotected contact occur? (tick all that apply)
Person was not thought to be a case at the time
Person had been a suspect case, but had tested negative for Ebola on the first test
PPE were not available to wear
Other (specify): ____________________________________________________________________

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Case ID number: ______________________

8. Infection prevention and control (HCW, colleague, supervisor)
Healthcare facility workplace/s use of PPE and standard precautions: (specify different workplaces)
During possible time of exposure, was PPE used?
HCF 1: Yes No
Don’t know
No Don’t know
HCF 2: Yes
Describe what items (tick all mentioned)
HCF 3: Yes
No Don’t know

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☐ Disposable gown ☐ Coverall (Tyvek-like)
☐ Goggles
☐Facemask
☐ Cap
☐ Hood
☐ Closed resistant shoes

☐ Single gloves
☐ Double gloves
☐ Coverall (Tychem-like) ☐ Face shield
☐N-95 or above respirator ☐ Waterproof apron
☐ Shoe covers
☐ Rubber boots
☐ Leg covers
☐ Other (specify): ______________________________________________

If different workplaces have different procedures please specify difference: _______________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Don’t know
Did the HCW apply duct tape to secure PPE?
HCF 1: Yes No
HCF 2: Yes
No Don’t know
HCF 3: Yes
No Don’t know
How long would HCW usually work while wearing PPE per entry in the isolation area?
HCF 1_____(hours)
HCF 2_____(hours)
HCF_____(hours)

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☐Yes ☐No ☐ Don’t know
☐ Yes ☐ No ☐ Don’t know
☐ Yes ☐ No ☐ Don’t know
At possible time of exposure, was hand hygiene performed appropriately? ☐Yes ☐No ☐Don’t know
Were hand hygiene products available at time of exposure?
HCF 1: ☐Yes ☐No ☐ Don’t know
HCF 2: ☐ Yes ☐ No ☐ Don’t know
HCF 3: ☐ Yes ☐ No ☐ Don’t know
If Yes, which
(specify HCF) ☐ Running (tap) water ☐ Chlorinated water from reservoir
☐ Soap
☐ Disposable towels ☐ Alcohol antiseptic ☐Other (specify): ________________
At possible time of exposure, were safety boxes available?
HCF 1: ☐Yes ☐No ☐ Don’t know
HCF 2: ☐ Yes ☐ No ☐ Don’t know
HCF 3: ☐ Yes ☐ No ☐ Don’t know

Was a ‘buddy’ system (co-worker observing) used to take off PPE? HCF 1:
HCF 2:
HCF 3:

Could the HCW identify other deficiencies in infection prevention and control at their workplaces?
(tick all that apply)
HCF 1
HCF 2
HCF 3
No triage available
Proper isolation of patients not available
PPE not consistently available or complete
Improper or inadequate training of staff
Hand hygiene facilities unavailable
Other (specify)

COMMMUNITY: During possible time of exposure, was PPE used during all community exposures?
Yes
No
Don’t know
If Yes, describe PPE use:________________________________________________________________
_____________________________________________________________________________________
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