Contact Tracing Form for Health Care Workers caring for

---

Overview

Front page
portrait

---

Sheet 1: Front page

			Contact Tracing form for Health Care Workers Caring for Ebola patients
Instructions: The following form can be used to prospectively evaluate health care workers for potential risks and appropriate PPE while caring for an Ebola case. It is intended only as a template to faciliate data collection.

---

Sheet 2: portrait

EVD Tracking Form for Healthcare Workers with Direct Patient Contact

Page #:

Patient ID:

(e.g. nurses, physicians, respiratory therapists, others)

Employee Information Employee ID:

Name:

Sex:

M

F

Address (street, city, county, state):

Age (years):

Employee position:

Phone number(s):

Site(s) provided care (list all, e.g. ER, ICU, lab, etc.):

Date, at beginning of shift

Notes

Worked shift on this day? (Y/N) If no, then STOP.

If yes, was shift overnight? (Y/N)

Provided care to patients, other than EVD or suspected EVD patients? (Y/N)

Provided care to patient with EVD or suspected EVD? (Y/N) If no, then STOP.

Entered patient's room/same enclosed area? (Y/N)

# times entered room

Cumulative time in room (hours)

PPE worn: 2 Pairs of gloves? (Y/N)

Mid-calf gown? (Y/N)

Impermeable coveralls or gown? (Y/N)

Apron? (Y/N)

Boot covers/shoe covers? (Y/N)

Surgical hood/neck cover? (Y/N)

N95 respirator & face shield? (Y/N)

PAPR & hood? (Y/N)

Supervised while doning PPE? (Y/N)

Supervised while doffing PPE? (Y/N)

# times doffed PPE during shift?

PPE soiled with stool? (Y/N)

PPE soiled with blood? (Y/N)

PPE soiled with other body fluids? (Y/N)

Any issues with PPE (e.g. exposed skin, readjustments)? (Y/N; if yes, explain in notes)

Any percutaneous exposures (i.e. needle sticks, cuts)? (Y/N; if yes, explain in notes)

Any known direct exposures to your skin/mucous membranes with patient's blood/body fluids? (Y/N; if yes, explain in notes)

Any known direct skin-skin exposure to patient? (Y/N; if yes, explain in notes)

Touched patient (regardless of PPE)? (Y/N)

Helped patient to commode? (Y/N)

Placed, emptied or adjusted rectal tube ? (Y/N)

Touched/interacted with foley catheter or changed bag? (Y/N)

Intubated patient? (Y/N)

Suctioned patietn? (Y/N)

Placed IV or central venous catheter? (Y/N)

Drew blood from patient ? (Y/N)

Performed finger stick on patient? (Y/N)

Repositioned patient? (Y/N)

Bathed the patient? (Y/N)

Cleaned up vomit? (Y/N)

Cleaned up stool? (Y/N)

Changed sheets? (Y/N)

Filled or placed biohazard waste bags into clearn containers? (Y/N)

Employee's initials