Ebola Tracking Form for Laboratory Personnel

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Overview

Front page
portrait

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Sheet 1: Front page

	Contact Tracing Form for Laboratory Workers Handling Specimens from Ebola patients
	Instructions: The following form can be used to prospectively evaluate laboratory workers for potential risks while handling specimens from an Ebola case. It is intended only as a template to faciliate data collection.

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Sheet 2: portrait

Ebola Tracking Form for Laboratory Personnel

Page #:

Patient ID:

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)

Handled or processed specimens from an Ebola or suspected Ebola patient? (Y/N) If no, then STOP.

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

Mid-calf gown? (Y/N)

Impermeable coveralls or gowns? (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 donning PPE? (Y/N)

Supervised while doffing PPE? (Y/N)

Any issues with handling/processing samples from Ebola patients (e.g. soil on outside of tube)? (Y/N; if yes explain in notes)

PPE soiled with blood from Ebola patient? (Y/N)

PPE soiled with other body fluids from Ebola patient? (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)

Always handled/processed patient samples with recommended PPE? (Y/N; if no, explain in notes)

Employee's initials