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 #
Surveyor name
Date of Assessment (dd/mm/yyyy)
2. Facility Name & Spatial Data
Location Name
Street Address
City
State
Zip
Location Description
Latitude/Longitude
Number of Employees
Contact:
Phone (work)
Phone (cell)
Email
Assessment Item
Yes NO Comment
Clinical Director
Employee Health Director
Facility Engineer
Names of Persons Interviewed:
Lead Admin:
Dietary Chief
01 Are staffing levels of health care workers (HCWs)
adequate? If no, describe in comments box
02 Are HCWs working unusual or extra shifts?
03
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?
List method
06 Have any trends in illness/injury in patients been
observed?
07 Are personal protective equipment (non-latex gloves,
N-95 respirators, faceshields) available to HCWs?
08 What health and safety concerns are most important
to workers?
List:
09
Is safety training provided to new HCWs and
volunteers?
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
control?
13 Are procedures in place for:
a.
Infectious waste handling
b.
Isolation of potentially infectious patients
c. Handling of laundry
d. Cleaning the facility
14 Are there bargaining units or Unions for HCWs at
the site?
15
Is information or technical assistance needed for any
specific occupational risks or exposures?
16 Has facility management identified any