The CONNECT Study Questionnaire

Mount Sinai Hospital and

Samuel Lunenfeld Research InstituteNoveMbeR 2006

Please fill out the following questionsDemographics

1. Sex M F

2. Year of Birth: ________________

3. Primary ward or location within which you work: ____________________________________ or Rotating/Multiple

4. We would like to ask: Does your pay cheque come from:

MSH SLRI U of T

Volunteer Other (e.g. physician, UHN)

5. Occupation: (Please check one answer, the list continues on pg 2/11)

Staff physician, specialty:_______________________

Nurse

Receptionist

Volunteer

Patient Attendant/Sitter

Medical Imaging Technologist

Pharmacist

Medical Student

Postgraduate Medical Trainee

Other student discipline:

Ward Clerk

Physiotherapist/Occupational Therapist

Respiratory Therapist

Housekeeping

Social Worker

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Service Assistant

Central Supply Technician

Other, specify:_____________________________________

6. Do you also work in any other health care settings such as another hospital, clinic, nursing home, etc.?

No If yes: Employed Volunteer Cross-coverage

7. Are you employed in any other non-health care settings?

No Yes If yes, please specify: ___________________________________________

8. Number in household (including self):______________

9. Ages of others in household (if any):______________

10. Type of dwelling: Detached House Townhouse

Condominium/Apartment, please specify number of units:

<50 50-99 100-199 200+ units

Other, specify: _________________________________

11. On average, how many hours do you work at this hospital per week? ______________________

Occupational History

The following questions ask you about your activity in a typical week.

In order to understand how infections spread through a hospital setting, we need to know your physical movement in a typical week. Think of it as tracking your every move. That is the best way for us to see how infections spread. As you complete the following questions, think of all the locations you have worked or visited during the week. We are asking that you list the locations and how long you were at the location. Remember to include things like going to Xray with a patient, dropping off samples to the lab, going down the elevator to the cafeteria or standing in line at the Second Cup.

*Please note the information you provide is for a typical week .

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As you complete these questions, imagine that you are watching a video of your movement and you are writing down all that you see. The more you can tell us, the better we may understand how infections can be spread. If you cannot remember a typical week then try to remember the last full week you worked.

12. Please check all the areas you worked in or visited during a typical week and enter the hours and/or minutes in spaces provided.

600 UNIVERSITY AVENUE

2nd Floor

HRS MIN. HRS MIN.1st Floor

HRS MIN. HRS MIN.

1st Floor-Samuel Lunenfeld Research Institute Biomedical EngineeringCentral Dispatch StoresCommunications (Switchboard & Locating)Graphics and New MediaHouse Staff Locker RoomHousekeepingImage CentreInformaticsMailroomMechanical Stores

Medical Student LoungePeter Sullivan Centre for Int’l. HealthPrint ShopReceiving DockRespiratory TherapySterile ProcessingStorage AreaStudent Locker RoomUniform DistributionUnion Office

AudiologyAuxiliaryCafeteriaEmergency Department AdministrationInfection ControlNutrition & Food ServicesOtologic Function Unit

Patient Simulation ReceivingStaff Locker Room -FemaleStaff Locker Room -MaleSurgical Skills LabVolunteer ServicesOther___________

3rd Floor/Main Level HRS MIN.

Indigo SpiritLobby CaféMedical EducationMurray St. Info Desk

HRS MIN.

AdmittingBioethicsChinese Community Outreach Programs

*Please note the information you provide is for a typical week .

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4th Floor

5th Floor HRS MIN. HRS MIN.

HRS MIN. HRS MIN.

Ambulatory Internal Medicine ClinicDentistry Gastroenterology OfficesGeneral SurgeryIntern/Med. Student LockeroomMedical Record ServicesMedicine OfficesOphthalmology

Orthopaedic Surgery OfficesOtolaryngology (ENT)Outpatient LabPre-Admission UnitPulmonary Function LabSocial Work (Medical Social Services)Other______________

Bone and Tissue BankCystoscopyDay SurgeryFracture ClinicInterventional RadiologyIVF Lab

Medical Imaging CT Scan MRI Ultrasound XrayOperating RoomPatient ReceptionPost Anaesthesia Unit (Recovery Room)Other______________

Human ResourcesOutpatient PharmacyPatient Relations/ Risk ManagementPayroll Second CupSecurity DeskSurgical Waiting RmSynagogueOther_____________

HRS MIN.HRS MIN. 3rd Floor/Main Level con’t.

*Please note the information you provide is for a typical week.

Communications / MarketingDentistry Admin OfficeDoctor’s LoungeElective Outpatient SurgeryEmergency DepartmentExecutive OfficesFinance/AccountingFire Control RoomG. Turner Dept of Nursing

5 of 11 *Please note the information you provide is for a typical week .

8th Floor HRS MIN. HRS MIN.

9th Floor HRS MIN. HRS MIN.

8th Fl. Samuel Lunenfeld Research Institute

MechanicalOther____________

9th Floor Samuel Lunenfeld Research Institute 9S- Day Treatment & Community

9S- Psychiatry/ Outreach ProgramPsychiatry AdminPsychotherapy Research OfficesOther ___________

7th Floor

HRS MIN.

Breast Feeding CentreBreast Feeding ShopBreast Pump RoomsCare by Parent RoomsEndocrinology Offices7th Level-Labour & DeliveryLevel II NurseryNICU (Level III Nursery)

Obstetrics - Antepartum/ Combined CareObstetrics Day UnitParent LoungePatient Family Areas (Waiting Rooms etc)Perinatology OfficesOther

MIN.HRS

HRS MIN. HRS MIN.6 th Floor

Autopsy SuiteAndrology ClinicBio-Chemistry LabBlood Transfusion SrvcsBone DensityBone and MineralCell Biology LabChromatographyCytologyEducation Centre (6th floor classroom)Electron Microscopy

Endoscopy UnitHistology LabMorgueNuclear MedicinePathology and Lab Medicine OfficesRapid Response LabResearch Respiratory Medicine (Therapy)Urology-SurgeryOther ____________

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15th Floor

12th Floor HRS MIN.12N- Ambulatory Oncology Unit12S- Medical UnitEngineeringFetal Medicine CentreDoctors Offices NorthRuth Burnett Centre for Outpatient Oncology

Marvelle Koffler Breast Centre Biopsy Chemotherapy Mammography Reception/ Waiting RoomPharmacy SatelliteOther _____________

HRS MIN.

14th Floor Classroom14N- Surgical Oncology Unit14S- Inflammatory Bowel Unit

14th Floor

Microbiology LabStep Down Unit 14NOther _____________

HRS MIN. HRS MIN.

Anna Prosserman Heart Function ClinicChaplaincyComputer Training

Human Rights and Diversity OfficesMedical Education ClassroomsPharmacyOther _____________

HRS MIN.

HRS MIN.

*Please note the information you provide is for a typical week .

10th Floor

HRS MIN. HRS MIN.

10th Fl Samuel Lunenfeld Research Institute10th Level- Obstetrics - Post Partum Nursing UnitInfant Hearing Program Offices

HRS MIN.Level I NurseryObstetrics & Gynecology OfficesResearch Ethics Board OfficesOther _____________

11th Floor 11N- Inpatient Unit (Ortho, Gynecology, Dental/ENT /Eye)11S- Inpatient Unit (Ortho/ Sarcoma)Liver Study UnitOccupational Therapy

Physiotherapy Gymnasium Sports Clinic Therapeutic Pool Wasser Pain Mgmt CentreOther ___________

HRS MIN.

7 of 11 *Please note the information you provide is for a typical week .

60 MURRAY STREET

Occupational Health & SafetyOphthalmology

Toronto Centre Phenogenomics Bio-informaticsOther ____________

Main Level- 2nd FloorRebecca MacDonald Centre Patient RegistrationSecurity Office

Ambulatory LabRheumatologyOther ____________

HRS MIN.HRS MIN.

HRS MIN. HRS MIN.

16th Floor16N- Cardiology/MedicineCardiac Research LabCoronary Care Unit (CCU)

ElectrocardiogramPacemaker ClinicOther _____________

17N- Medicine/Geriatric17S- Medicine/GeriatricStep Down Unit

17th FloorResident’s Room & Staff LoungeOther ____________

HRSHRS MIN.

HRS MIN. HRS MIN.

HRS MIN. HRS18th FloorIntensive Care Unit (ICU)18th Floor FoyerAuditoriumChaplaincyComputer Training Room

ICU Waiting RoomICU OfficesStudent’s LoungeSidney Liswood LibraryOther______________

Ground Floor

MIN.

MIN.

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CytogeneticsCytopathologyHuman ResourcesInformatics Technovision Unit

LIS OperatorsOrganization DevelopmentOther __________

HRS MIN.

HRS MIN.

8th Floor

OPG

Main Registration AreaOut Patient LabFamily PlanningHigh Risk Pregnancy ClinicIn-Vitro FertilizationLow Risk Obstetric ClinicMaternal Infant ProgramMenopause ClinicPremature Ovarian Failure ClinicPrenatal Diagnosis & Medical GeneticsPrenatal Education ProgramSpecial Pregnancy Program

Sperm BankWomen’s UnitUrodynamics LabUltrasound –PrenatalReception/Waiting AreaDoctor’s Offices NorthDoctor’s Offices SouthSocial Work OfficeReproductive Biology UnitOther ___________

3rd Floor

HRS MIN.HRS MIN.

3rd FloorConference RoomsDigestive Disease Clinical Research CentreHousekeepingOther________________

5th FloorEpidemiology and Biostatistics OfficesProsserman Centre for Health ResearchLeadership Sinai Centre for Diabetes Other_________________

HRS MIN. HRS MIN.

HRS MIN.4th FloorFamily MedicineTemmy Latner Centre for Palliative CareOther___________

6th FloorMurray Koffler Urologic Wellness CentreCancer Genetics LabAdvanced Centre for Detection of CancerOther___________

HRS MIN.

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13. I answered the above questions based on:

a typical week or last week or the last full week worked

The following questions ask you about your activity on a typical day. If you cannot remember a typical day then try to remember the last full day you worked.

14. On a typical day, with how many patients are you in direct contact (within 1 meter/3 feet)?

<5 5-9 10–19 20-29 30-39 40-49 50+ patients

15. on average, how many minutes do you spend in direct contact with any one patient per day (within 1 meter/3 feet)

< 5 5-10 11-20 20+ minutes

16. On average, with how many patients do you have indirect contact (same room but not closer than 1 meter/3 feet) per day?

1–5 6-10 11–15 16-20 21-25 26-30 30+ patients

17. On average, with how many health care co-workers (HCW) do you have direct contact per day (within 1 meter for at least two minutes)?

1–5 6-10 11–15 16-20 21-25 26-30 30+ HCWs

18. I answered the above questions based on:

a typical day or yesterday or the last full day worked

19. In your experience, how regularly do your colleagues comply with disease infection control guidelines? Please circle your response, rated from 0 (full non-compliance) and 10 (full compliance).

Non-compliance Compliance 0 1 2 3 4 5 6 7 8 9 10

21. Usually, you have more than one contact with a patient on a shift. If you have more than one direct contact with the same patient on any given day, how regularly would you record your name in the patient’s chart? Please circle your response, rated from 0 (never record) and 10 (always record).

Never Always

0 1 2 3 4 5 6 7 8 9 10

22. Imagine a patient that is diagnosed with a respiratory tract infection (e.g. influenza, RSV, adenovirus) that is spread by droplets. Please check all precautions you would take when you are within three feet (1 metre) of this patient:

23. How regularly do you comply with recommended infection prevention measures for patients with respiratory tract infections noted above? Please circle your response, rated from 0 (never) to 10 (always).

Never Always

0 1 2 3 4 5 6 7 8 9 10

24. How regularly are you able to comply with MRSA precautions? Please circle your response, rated from 0 (never) to 10 (always).

Never Always

0 1 2 3 4 5 6 7 8 9 10

N95 mask (not fit tested)two pairs of gloves gown

surgical/procedure mask face or eye shield single pair of gloves

N95 mask (fit-tested)goggleshand washing

20. Sometimes, direct contact with a patient (within 1 metre) is a patient care activity that should be documented in the health record and sometimes not. On average, how regularly are your contacts with a patient recorded in the patient’s chart? Please circle your response, rated from 0 (never record) and 10 (always record).

Never Always

0 1 2 3 4 5 6 7 8 9 10

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25. Imagine a patient that is diagnosed with active pulmonary tuberculosis and who is coughing up mucus. Please check all precautions you would take when you are in the same room with this patient:

26. How regularly are you able to comply with recommended infection prevention measures for patients with active pulmonary tuberculosis who are coughing up mucus? Please circle your response, rated from 0 (never) to 10 (always).

27. Imagine a patient that is diagnosed with chickenpox and you have had the infection in childhood. Please check all precautions you would take when you are in the same room with this patient:

28. How regularly are you able to comply with recommended infection prevention measures for patients with chickenpox? Please circle your response, rated from 0 (never) to 10 (always).

Never Always

0 1 2 3 4 5 6 7 8 9 10

29. Do you get a yearly influenza vaccine?

No (never) Yes, every year Yes, but not every year

30. On average, how many times per year do you come down with a cough or cold illness? _________________________________________

Never Always

0 1 2 3 4 5 6 7 8 9 10

Thank you for completing this questionnaire. Please return the questionnaire to the study

center using the self-addressed envelope.

surgical/procedure mask face or eye shield single pair of gloves

N95 mask (not fit tested)two pairs of gloves gown

N95 mask (fit-tested)goggleshand washing

surgical/procedure mask face or eye shield single pair of gloves

N95 mask (not fit tested)two pairs of gloves gown

N95 mask (fit-tested)goggleshand washing

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If you are interested in the draw for a $50 gift certificate to Second Cup or Indigo, remove the draw number at the bottom of this page. Do not remove the matching number above it. The matching number will be removed once the questionnaire is received at the study office and it will be placed in a ballot box. Fifty random draws will take place during the study period and the winning numbers will be posted on the hospital intranet.

Do not remove this number:

Tear at the dotted line and keep this number to claim your prize.

Draw for a $50 gift certificate. Keep this number to claim your prize, if your number is drawn.