Interim Occupational Health and Safety Survey Tool – Hospitals and Medical Care Facilities
Centers for Disease Control and Prevention
Last Updated 09/03/2005 17:00
1. Surveying Agency Data
Agency/Organization doing the assessment Group #
Date of Assessment (dd/mm/yyyy)
2. Facility Name & Spatial Data
Number of Employees
Yes NO Comment
Employee Health Director
Names of Persons Interviewed:
01 Are staffing levels of health care workers (HCWs)
adequate? If no, describe in comments box
02 Are HCWs working unusual or extra shifts?
Is a program in place to provide and monitor HCW
health and safety, including mental health?
04 Have more HCW illnesses/injuries than typically
seen been observed since Katrina?
05 Are HCW illness/injury data collected?
06 Have any trends in illness/injury in patients been
07 Are personal protective equipment (non-latex gloves,
N-95 respirators, faceshields) available to HCWs?
08 What health and safety concerns are most important
Is safety training provided to new HCWs and
10 Were PPE requirements included in the training?
11 Were standard precautions included in the training?
12 Are staff present who are trained in infection
13 Are procedures in place for:
Infectious waste handling
Isolation of potentially infectious patients
c. Handling of laundry
d. Cleaning the facility
14 Are there bargaining units or Unions for HCWs at
Is information or technical assistance needed for any
specific occupational risks or exposures?
16 Has facility management identified any