| First Name |
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| Last Name |
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| Primary Email |
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| Hospital / Facility Name |
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| City |
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| State |
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| Zip |
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Are you a CNA/NNOC Member?
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The Basics:
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| Are there infected cases currently on your unit? |
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| * If yes, how many patients? |
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Are you aware of any nurses in your facility who have been infected? |
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| * If yes, how many nurses? |
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Patient & RN Safety:
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Have you received training on how to care for suspected or confirmed cases of the H1N1 virus? |
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* If yes, when was the last training date?
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Does your facility have a screening system in place for identifying and isolating individuals with flu-like symptoms upon entering the facility?
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Is there a designated area to triage suspected cases separate from the general ER population?
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Is the hospital communicating to you as to which patients have or are suspected to have H1N1 influenza?
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Have you been instructed on what to do if you or another caregiver on your unit is exposed to the virus by a patient?
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Has your facility established a non–punitive leave and sick policy for RNs who contract the H1N1 virus? |
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N-95 Masks:
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Does your hospital policy require N-95 masks for all exposures to potentially infected H1N1 patients?
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Do nurses on your unit have access to N-95 respirator masks?
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Has staff been fit tested and trained on the proper use of N-95 masks?
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Is there an adequate supply of N-95 masks?
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Are you expected to reuse the N-95 Masks?
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Other Protective Concerns:
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Do nurses on your unit have access to protective eyewear and gowns?
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* If not both, which?
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Are patients with flu-like symptoms on your unit isolated?
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Is your facility offering staff the H1N1 influenza Vaccination?
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Does your facility have a mandatory vaccination policy for all healthcare workers in all units?
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Additional Information - Optional:
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| Is there anything else you’d like to add? |
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| Are there any innovations you’ve seen that you would like other nurses to know about? |
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