Form 2 Healthcare Workers Screening Module

SCREENING MODULE Form Approved

7/23//10 OMB No. 10AP-xxxx

Expiration Date: XX/XX/2011

PROGRAMMING INSTRUCTIONS APPEAR IN BLUE

In order to determine whether you are eligible to participate, please answer the following 7 questions.

display calendar highlighting the past 7 calendar days for all questions, except fOr pentamidine in Question 1 (DISPLAY CALENDAR HIGHLIGHTING PAST 30 CALENDAR DAYS).

1.	At any time in the past 7 calendar days, did you administer any of the following in aerosolized form to patients? TOBRAMYCIN (TOBIR), AMIKACIN (AmikinR) or COLISTIN RIBAVIRIN (VirazoleR) OR At any time in the past 30 calendar days, did you administer PENTAMIDINE (NebupentR) in aerosolized form to patients?	Yes LINK TO MODULE A No
2.	At any time in the past 7 calendar days, did you compound (i.e., mix or prepare) ANTINEOPLASTIC AGENTS? Antineoplastic agents are also known as chemotherapeutic, anti-cancer, or cytotoxic drugs.	Yes LINK TO MODULE B No
3.	At any time in the past 7 calendar days, did you administer ANTINEOPLASTIC AGENTS to patients? Antineoplastic agents are also known as chemotherapeutic, anti-cancer, or cytotoxic drugs.	Yes LINK TO MODULE C No
4.	At any time in the past 7 calendar days, did you use ETHYLENE OXIDE (EtO) or HYDROGEN PEROXIDE GAS PLASMA to chemically sterilize medical devices, instruments or supplies?	Yes LINK TO MODULE D No
5.	At any time in the past 7 calendar days, did you use any of the following to chemically disinfect medical devices, instruments or supplies? GLUTARALDEHYDE (e.g., Cidex®, ColdSport®, Endocide®, Glutacide®, Hospex®, Metricide®, Onicide®, Rapicide®, Sonacide®,Sporicidin®, Wavicide®); ORTHOPHTHALDEHYDE (e.g., Cidex OPA®); PERACETIC ACID (e.g., Steris® system); HYDROGEN PEROXIDE (e.g., Accell®, Optim®, Sporox®); OR HYDROGEN PEROXIDE and PERACETIC ACID (Acecide®, Metrex®, Peract®)	Yes LINK TO MODULE E No
6.	At any time in the past 7 calendar days, did you work within 5 feet of the source of SURGICAL SMOKE?	Yes LINK TO MODULE F No
7.	At any time in the past 7 calendar days, did you personally administer ANESTHETICS as a gas? Please do not include instances where you supervise others who administer anesthetic gases. Anesthetic gases include nitrous oxide, desflurane, sevoflurane, halothane, enflurane and isoflurane	Yes LINK TO MODULE G No

If Respondent marks ‘YES’ to ONLY ONE OF THE 7 SCREENING questions GO to LINKED HAZARD MODULE, then to core module, then exit survey.

If Respondent marks ‘YES’ to MORE THAN ONE OF THE 7 SCREENING questions  LIST chemical agents associated with these questions (all chemical agents are listed below for illustration purposes).

Please rank top two chemical agents in order of most to least used/exposed. Use “1’ for most used/exposed and “2’ for second most used/exposed. allow only one “1”’selection and one “2” selection for questions r1-r7.

If ONE of the top two chemical agents is targeted to professional organization OF r espondent GO to targeted hazard module, then to core module, then to (optional) remaining hazard module.

If NONE OF THE TOP TWO CHEMICAL AGENTS ARE TARGETED TO PROFESSIONAL ORGANIZATION OF respondent GO to hazard module FOR HIGHEST RANKED AGENT(S), then to core module, then to optional remaining hazard module (FOR SECOND HIGHEST RANKED AGENT(S).

R1.	TOBRAMYCIN (TOBIR), AMIKACIN (AmikinR) COLISTIN, RIBAVIRIN (VirazoleR) or PENTAMIDINE (NebupentR)	Provide DROP DOWN LIST OF “1” AND “2”; LINK TO MODULE A
R2.	(Prepare) ANTINEOPLASTIC AGENTS (also known as chemotherapeutic, anti-cancer, or cytotoxic drugs).	PROVIDE DROP DOWN LIST OF “1” AND “2”; LINK TO MODULE B
R3.	(Administer) ANTINEOPLASTIC AGENTS (also known as chemotherapeutic, anti-cancer, or cytotoxic drugs).	PROVIDE DROP DOWN LIST OF “1” AND “2”; LINK TO MODULE C
R4.	ETHYLENE OXIDE (EtO) or HYDROGEN PEROXIDE GAS PLASMA	PROVIDE DROP DOWN LIST OF “1” AND “2”; LINK TO MODULE D
R5.	GLUTARALDEHYDE (e.g., Cidex®, ColdSport®, Endocide®, Glutacide®, Hospex®, Metricide®, Onicide®, Rapicide®, Sonacide®,Sporicidin®, Wavicide®); ORTHOPHTHALDEHYDE (e.g., Cidex OPA®); PERACETIC ACID (e.g., Steris® system); HYDROGEN PEROXIDE (e.g., Accell®, Optim®, Sporox®); or HYDROGEN PEROXIDE and PERACETIC ACID (Acecide®, Metrex®, Peract®)	PROVIDE DROP DOWN LIST OF “1” AND “2”; LINK TO MODULE E
R6.	SURGICAL SMOKE	PROVIDE DROP DOWN LIST OF “1” AND “2”; LINK TO MODULE F
R7.	ANESTHETIC GASES (includes nitrous oxide, desflurane, sevoflurane, halothane, enflurane and isoflurane)	PROVIDE DROP DOWN LIST OF “1” AND “2”; LINK TO MODULE G

If RESPONDENT marks ‘No’ to all 7 SCREENING questions GO to Question E8

E8.	In the past 7 calendar days, what was your working status?	Working for pay at a job or business END SURVEY, ‘THANK YOU’ STATEMENT Working, but not for pay, at a family-owned job or business (e.g., volunteer, student trainee) END SURVEY, ‘THANK YOU’ STATEMENT Not working at a job or business GO to Question E9
E9.	What was the main reason for not working in the past 7 calendar days?	On layoff (temporary or indefinite) Slack work/business conditions Waiting for new job to begin Vacation/personal days Own illness/injury/medical problems Child care problems Other family/personal obligation Maternity/paternity leave Labor dispute Weather affected job School/training Civic/military duty Looking for work Retired Disabled Other (please specify):_________________ All RESPONSES GO to Question E10
E10.	In the past 30 calendar days, what was your working status?	Working for pay at a job or business END SURVEY, ‘THANK YOU’ STATEMENT Working, but not for pay, at a family-owned job or business (e.g., volunteer, student trainee) END SURVEY, ‘THANK YOU’ STATEMENT Not working at a job or business GO to Question E11
E11.	What is the main reason for not working in the past 30 calendar days?	On layoff (temporary or indefinite) Slack work/business conditions Waiting for new job to begin Vacation/personal days Own illness/injury/medical problems Child care problems Other family/personal obligation Maternity/paternity leave Labor dispute Weather affected job School/training Civic/military duty Looking for work Retired Disabled Other (please specify):_________________ All RESPONSES END SURVEY, ‘THANK YOU’ STATEMENT

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