1 Start 2 Complete There are efforts across the globe directed at identifying health care worker (HCW) SARS-CoV-2 exposures and exposure risk as a function of their roles and responsibilities. AHN desires to understand current seroprevalance of SARS-CoV-2 in our team members who have cared for COVID-19 positive patients in an in-patient setting. AHN is offering these employees a completely voluntary opportunity to complete a survey related to their demographics, potential exposures, and PPE use. Qualified HCWs will be offered an antibody test. The results of the test will be associated with the survey responses, but not to the individual providing the sample. HCWs will not receive any individualized results. The aggregate results will, however, inform future decisions about our system’s practices regarding patient isolation, HCW personal protective equipment, and exposure risks associated with future developments of the COVID-19 pandemic. 1. Have you had direct contact with COVID positive patients at work? * Yes No Thank you for participating in the survey. Based on your response, you do not qualify for the antibody test. Please exit the survey. 2. Have you experienced influenza-like illness since January 1st 2020? * Yes No Estimated date of illness 3. Have you had direct contact with confirmed COVID-19 patients at home or outside of work? * Yes No Describe contact 4. Have you been previously tested (nasopharyngeal swab) for COVID-19? * Yes No If answer is NO, Please answer N/A for question 5 Date of test 5. Were you diagnosed with COVID-19? * Yes No N/A 6. Age: * < 25 25-34 35-44 45-54 55-64 65 or older 7. Gender: * Male Female 8. Race: * White Hispanic or Latino Black or African American Native American or American Indian Asian/Pacific Islander Other 8. Race: Other 9. Role: * Physician Physician Assistant Nurse Practitioner Registered Nurse Assistant nurse or nurse technician (or equivalent) Radiology/x-ray technician Phlebotomist Physical therapy/occupational therapy Respiratory therapy Nutrition/dietary Environmental Service Transport Other 9. Role: Other 10. Location (please select all that apply): * ER ICU General Medical/Surgical floor GI lab Pulmonary lab Operating room Radiology Other 10. Location (please select all that apply): Other 11. Date of 1st exposure to confirmed COVID-19 patient * 12. Date of most recent HCW exposure to a confirmed COVID-19 patient * 13. Closest level of care provided (please select one) * Direct physical contact Within 3 feet Within 6 feet In room 14. How many confirmed COVID-19 have you treated at this level? * 1 2 to 5 6 to 10 More than 10 15. Including those described above, with how many confirmed COVID-19 patients did you have face-to-face contact? * 1 2 to 5 6 to 10 10 to 15 15-20 20-30 More than 30 16. Did you have direct contact with the environment where the confirmed COVID-19 patient was cared for) (i.e. – bed, linens, medical equipment, bathroom) * Yes No 17. Were you involved in health care interactions (paid or unpaid) in another health care facility during the period above (check all that apply)? * Ambulance Home care Long term acute care (LTAC) Skilled nursing facility (SNF) Assisted living facility N/A Other... 17. Were you involved in health care interactions (paid or unpaid) in another health care facility during the period above (check all that apply)? Other... For the questions below, aerosol generating procedures include: Intubation, extubation, and related procedures such as manual ventilation and open suctioning; Bronchoscopy; Tracheostomy; Trans-esophageal echocardiogram (TEE); Upper endoscopy such as EGD; Medication administration via continuous nebulizer; Induction of sputum; Cardiopulmonary resuscitation (CPR); Anytime ventilator circuits are broken; High flow nasal oxygen (also called high-flow nasal cannula); Non-invasive ventilation such as BiPAP and CPAP 18 . During interactions described above with COVID-19 patient WHEN NOT PARTICIPATING IN AEROSOL GENERATING PROCEDURES (non-AGPs), did you wear PPE? * Yes No If NO, Please answer N/A on questions 19-28 19. How often did you use gloves in the non-AGP encounters referenced above? * Always, as recommended Most of the time (> 75%) Occasionally (50 - 75%) Rarely (< 50%) Never N/A 20. How often did you use N95, P100, or N100 mask in the non-AGP encounters referenced above? * Always Most of the time (> 75%) Occasionally (50 - 75%) Rarely (< 50%) Never N/A 21. How often did you use face shield / goggles in the non-AGP encounters referenced above? * Always, as recommended Most of the time (> 75%) Occasionally (50 - 75%) Rarely (< 50%) Never N/A 22. How often did you use surgical mask/ear loop mask in the non-AGP encounters referenced above? * Always Most of the time (> 75%) Occasionally (50 - 75%) Rarely (< 50%) Never N/A 23. How often did you use disposable gown in the non-AGP encounters referenced above? * Always, as recommended Most of the time (> 75%) Occasionally (50 - 75%) Rarely (< 50%) Never N/A 24. Did you remove and replace your PPE according to protocol in the non-AGP encounters referenced above (e.g. when medical mask became wet, disposed the wet PPE in the waste bin, performed hand hygiene, etc.)? * Always, as recommended Most of the time (> 75%) Occasionally (50 - 75%) Rarely (< 50%) Never N/A 25. Did you perform hand hygiene before and after touching the COVID-19 patient in the non-AGP encounters referenced above (whether or not you were wearing gloves)? * Always, as recommended Most of the time (> 75%) Occasionally (50 - 75%) Rarely (< 50%) Never N/A 26. Did you perform hand hygiene before and after any clean or aseptic procedure was performed in the non-AGP referenced above?(e.g. while inserting a peripheral vascular catheter, urinary catheter, intubation, etc.)? * Always, as recommended Most of the time (> 75%) Occasionally (50 - 75%) Rarely (< 50%) Never N/A 27. Did you perform hand hygiene after exposure to body fluid in the non-AGP encounters referenced above? * Always, as recommended Most of the time (> 75%) Occasionally (50 - 75%) Rarely (< 50%) Never N/A 28. Did you perform hand hygiene after touching the patient’s surroundings (bed, door handle, etc.), regardless of whether you were wearing gloves in the non-AGP encounters referenced above? * Always, as recommended Most of the time (> 75%) Occasionally (50 - 75%) Rarely (< 50%) Never N/A 29. Were you present in the patient room WHEN ANY AEROSOL-GENERATING PROCEDURES (AGP) were performed on the patient (check all that apply)? * Intubation Extubation Nebulized treatment Open airway suctioning Tracheostomy Bronchoscopy Cardiopulmonary resuscitation (CPR) None Other 29. Were you present in the patient room WHEN ANY AEROSOL-GENERATING PROCEDURES (AGP) were performed on the patient (check all that apply)? Other 30. During AGPs on a COVID-19 patient, did youwear personal protective equipment (PPE)? * Yes No N/A IF YOU WERE PRESENT WHEN ANY OF THE AGPS WERE PERFORMED PLEASE ANSWER N/A on Questions 31-39 31. During AGPs, how often did you wear single-use gloves? * Always, as recommended Most of the time (> 75%) Occasionally (50 - 75%) Rarely (< 50%) Never N/A 32. During AGPs, how often did you wear N95, P100, or N100 mask or equivalent respirator? * Always, as recommended Most of the time (> 75%) Occasionally (50 - 75%) Rarely (< 50%) Never N/A 33. During AGPs, how often did you wear a surgical/ear loop mask instead of a N95, P100, or N100 mask or equivalent respirator? * Always Most of the time (> 75%) Occasionally (50 - 75%) Rarely (< 50%) N/A 34. During AGPs, how often did you wear face shield or goggles/protective glasses? * Always, as recommended Most of the time (> 75%) Occasionally (50 - 75%) Rarely (< 50%) Never N/A 35. During AGPs, how often did you wear a disposable gown? * Always, as recommended Most of the time (> 75%) Occasionally (50 - 75%) Rarely (< 50%) Never N/A 36. During AGPs, did you remove and replace your PPE according to protocol (e.g. when medical mask became wet, disposed the wet PPE in the waste bin, performed hand hygiene, etc.)? * Always, as recommended Most of the time (> 75%) Occasionally (50 - 75%) Rarely (< 50%) Never N/A 37. During AGPs, did you perform hand hygiene before and after touching the COVID-19 patient (whether or not you were wearing gloves)? * Always, as recommended Most of the time (> 75%) Occasionally (50 - 75%) Rarely (< 50%) Never N/A 38. During AGPs, did you perform hand hygiene before and after any clean or aseptic procedure was performed? * Always, as recommended Most of the time (> 75%) Occasionally (50 - 75%) Rarely (< 50%) Never N/A 39. During AGPs, did you perform hand hygiene after touching the patient’s surroundings (bed, door handle, etc.), regardless of whether you were wearing gloves? * Always, as recommended Most of the time (> 75%) Occasionally (50 - 75%) Rarely (< 50%) Never N/A 40. During a health care interaction with a COVID-19 patient, did you have any type of accident with body fluid/respiratory secretions? See below for examples * Yes No 41. Which accident (check all that apply) * Splash of biological fluid/respiratory secretions in the mucous membrane of eyes Splash of biological fluid/respiratory secretions in the mucous membrane of mouth/nose Splash of biological fluid/respiratory secretions on non-intact skin Puncture/sharp accident with any material contaminated with biological fluid/respiratory secretions N/A If you answered no, please go to question 40 Leave this field blank
