Influenza Healthcare Worker Case Report Addendum Form Page 2
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2In the 7 days prior to becoming ill with swine flu, on which unit types did you work?
(please indicate number of days worked in each category):
____Inpatient adult critical care (e.g., intensive care unit)
____Neonatal/pediatric critical care
____Inpatient adult ward (non-critical care)
____Inpatient pediatric ward (non-critical care)
____Operating room
____Outpatient clinic
____Emergency department
____Obstetrics or labor and delivery
____Other, specify: ____________________________________________________
____None (e.g., did not work)
____Not applicable
Healthcare Exposures
In the 7 days prior to becoming ill with swine flu, did you enter a patient’s room while the patient was present? ( if no
skip to Medical History Section)
_____Yes
_____No
In the 7 days prior to becoming ill with swine flu, did you have physical contact with any patient(s)?
_____Yes
_____No
In the 7 days prior to becoming ill with swine flu, did you enter the room of a patient (while the patient was present)
with any of the following respiratory illnesses (check ALL THAT APPLY):
___ Pneumonia
___ Upper respiratory tract infection
___ Flu-like symptoms
___ Don’t know
If yes, please indicate how often you used the following personal protective equipment upon entering their room:
a. gloves
Never
Some of the time
Most of the time
Always
b. gowns
Never
Some of the time
Most of the time
Always
c. surgical mask
Never
Some of the time
Most of the time
Always
d. N-95 respirator
Never
Some of the time
Most of the time
Always
e. face shield or
Never
Some of the time
Most of the time
Always
goggles
In the 7 days prior to becoming ill with swine flu, did you enter the room of any patient with swine flu (while the
patient was present)?
_____Yes _____No
If yes, please indicate how often you used the following personal protective equipment upon entering their room:
a. gloves
Never
Some of the time
Most of the time
Always
b. gowns
Never
Some of the time
Most of the time
Always
c. surgical mask
Never
Some of the time
Most of the time
Always
d. N-95 respirator
Never
Some of the time
Most of the time
Always
e. face shield or
Never
Some of the time
Most of the time
Always
goggles
Medical History
Are you taking any medication that might suppress your immune system (for example, prednisone or cyclosporine)
___ Yes ___ No ___ Don’t know,
Specify medication: ___________________________________
Do you have an autoimmune disease ___ Yes ___ No ___ Don’t know
Are you a current smoker? ___Yes
___No
Outcomes
How many days did you take off from work due to your swine flu illness?
________
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Parent category: Business