Title of Document - Care Providers of Minnesota



Monitoring of Health Care Workers Exposed to Person with Confirmed COVID-19Initial ‘Day Zero’ Phone Script | 4.11.2020Date of Call: ____/____/____ Time: _______ Interviewer: ___________________Name: ________________________________ DOB: ___/____/______ Age: _________Facility: _______________________________MN Case ID: ______________________Role: _________________________________Contact number(s): _____________________Email: ______________________Date of Last Exposure: ___/____/___ Plus 14 days: ___/____/___ (last monitoring date)Notes:Complete After Interview*MDH Risk Level: ____ Facility Risk Level (if any): ____If discrepant, told Lead? Y / NConcerning symptoms: Y / NPlans to be/is being tested for COVID-19: Y / N*This risk level goes into REDCap.FILL OUT A SEPARATE FORM FOR EACH HEALTH CARE WORKER.Speaking with person directly? YesNoSpeaking through an interpreter?YesNoName: _______________________Language: ___________________ Interpreter contact info: _________________What type of exposure is this? Circle one.Patient / LTC Resident / CoworkerIntroductionHello. My name is ______. I’m calling from Minnesota Department of Health. I’d like to speak with _______. I am calling with regard to your job as _____________ at ______________, where recently there was a confirmed case of COVID-19. The CDC has asked state and local health departments to speak with and monitor every person potentially exposed to COVID-19. Depending on the details of exposure, you may require public health monitoring for 14 days after your last exposure. Because you were last exposed to a positive patient on _____/____/____, for you, that 14-day period ends on _____/____/____ (14 days after last exposure to known infected patient). The goals of this approach are to keep track of your health status and to give you guidance on restrictions on your activities. During this period, a public health professional might contact you once daily to check on your health and to answer any questions you may have. Today, I am going to ask you for detail about your encounter(s) with COVID-positive person(s). Tennessen WarningRead to each health care worker monitored.Before asking for any private information, we are required by Minnesota state law to give you the following information regarding your participation and your right to privacy. We are collecting this information to help monitor your health, concerns, and needs and give you recommendations, because you have been identified as a close contact of a person who has been diagnosed with COVID-19. The only persons who will have access to private information from which you might be identified will be public health staff from the Minnesota Department of Health and staff from local public health who are directly working on COVID-19 response. If you become ill and need medical care, we might need to share your information with emergency services personnel or health care providers to help them assist you. Because your occupation involves health care, we may need to share information with an employer.You can refuse to provide this information to us, but you should know that if you do so, we may refer this matter to our medical/legal team to determine whether to seek a legal order.Understand/AgreeConcerns noted: _______________________________________________________Coordinated Monitoring with Your Employer and MDHMDH and healthcare facilities with COVID-19 cases coordinate monitoring of healthcare workers exposed to a COVID-19 patient, patient, or coworker. This includes sharing of information regarding healthcare worker health, illness, and quarantine status. If you do not want MDH to share the information that we collect from you with your employer, that is ok. It will not impact your relationship with MDH or your employer. However, you might be responsible for communicating your health information with both MDH and your employer. Do we have your permission to share your information with your employer through our coordinated monitoring system?YesNoBackground QuestionsI will now ask you some questions. What is your D.O.B.? ___/___/____ Age: _____What is your phone number? ______________________Is there another phone number you can provide in case we are unable to reach you on the first phone?YesWhat is that number? ______________________NoCan you provide the name and phone number of an emergency contact that we can call if we are unable to reach you?YesName and phone number: ______________________________No Do you have an email account that you check regularly?YesWhat is that email address? __________________________NoWhat is your home address or location at which you reside?Street Address: ___________________________________________City/Zip: _________________________________________________County: _________________________________________________ Is this where you will be staying through _____/____ (14 days from last exposure)? YesNoIf no, where will you be staying? Street Address: ______________________________________City/Zip: ______________________________________County: _____________________________________What are the name(s) and age(s) of other people currently sharing your household?____________________________________________________________________________________________________________________________________________________________________________________________________________________Where do you normally seek health care (both primary care clinic and preferred hospital)? Discuss plan for seeking care if you develop symptoms.______________________________________________________Are you employed or volunteer at a different health care facility, school, daycare facility or facility that involves patient care [other than your job at this facility]?______________________________________________________[If the person is employed at another healthcare facility] We might contact your employer to inform them about your monitoring, even if we do not recommend that you have any restrictions based on your risk level. Do you object?YesName and contact number: _______________________________NoIf the person objects: We must provide this information to your employer to protect the public’s health. Because you object, we will obtain a Commissioner’s order that lets us do this. Do you understand?NOTES FOR INTERVIEWER: If person works in a health care setting (clinic, doctor’s office, dental office, nursing home, hospital, etc.) or as a health care worker of some sort (aide, nursing assistant, nurse, physician, health tech, etc.), or if person works in a setting with direct contact with children such as a school or child care setting, get detailed information about this and let them know we may be calling back to follow-up with them regarding this information. 4432503346087 If symptoms are reported, say:Do not work while ill.You are a high-priority for testing. Please work with your employer or healthcare provider to set up testing. If have trouble getting tested, let us know.00 If symptoms are reported, say:Do not work while ill.You are a high-priority for testing. Please work with your employer or healthcare provider to set up testing. If have trouble getting tested, let us know.Current SymptomsAre you currently experiencing fever (subjective or measured), cough, shortness of breath, sore throat, or other symptoms? Note whether HCW plans to be tested.Yes Symptoms: _______________________________No Onset date: ____________Risk Questions and ExposureHas your employer assigned you an exposure risk level of low, medium, high?Yes Details: ___________ NoHas your employer told you to either stay out of work or continue reporting to work?YesDetails: ________________________________________________________NoWhat is the nature of your job at this facility?_____________________________________________________________ To what type of person were you exposed? Choose one.Patient Resident of LTC/congregate living CoworkerHave you had any contact with, or were present in the room with, a person diagnosed with confirmed COVID-19 infection? NOYesDescribe contact, including notes on masking of coworker interactions:________________________________________________________________________________________________________________________________________How long were you within 6 ft of the patient/resident/coworker? (cumulative time) <5 minutes 5-10 minutes ≥10 minutesWere you directly coughed on or exposed to any bodily secretions of the patient/resident/coworker?Yes NoIF THIS IS A COWORKER ASSESSMENT, SKIP TO RISK ASSESSMENT TABLE. Continue with the PPE questions for patient/resident exposures.Did you wear the following personal protective equipment?NotesEye protectionYesGogglesFace shieldPAPRNoRespiratory protectionYesN95 respiratorSurgical facemaskPAPRNoGownYesNoGlovesYesNoAt any point in caring for the patient/resident, did you have a breach in your PPE?Yes Details: _________________________________________________________NoWas the patient/resident wearing a facemask?Yes NoAt any point in caring for the patient/resident, was that person’s facemask removed? Make note of any removal for >2 minutes.YesDetails: _________________________________________________________NoDid you have direct contact with the patient (i.e., touch the patient)?Yes NoDid you have extensive body contact with the patient/resident (e.g., rolling/positioning)?Yes NoDid you perform, or were you in the room for, any procedure(s) likely to generate higher concentrations or respiratory secretions or aerosols? Yes NoNOTE FOR INTERVIEWER: Aerosol-generating procedures include endotracheal intubation, bronchoscopy, open suctioning of airway secretions, and sputum induction. Nebulization and NP/OP swab collection are not an aerosolizing procedures.Exposure Risk Assessment Patient or Resident Contact Risk levelRisk level is defined by any of the following situations involving PATIENT/RESIDENT contact.No Identifiable RiskRegardless of PPE, HCP who walk by patient or have no direct contact with patient or their secretions/excretions and no entry into the patient roomLow RiskHCP wearing all recommended PPE and adhering to all recommended infection control practicesHCP not using all recommended PPE who have only brief interactions with a patient, regardless of whether patient was wearing a facemask. Examples of brief interactions include: brief conversations at triage desk; briefly entering patient room without direct contact with the patient or patient’s secretions/excretions; or entering patient room immediately after the patient dischargeIf patient was wearing facemask:HCP wearing all recommended PPE (except a facemask instead of respirator)HCP wearing all recommended PPE but not wearing gown or gloves AND HCP did not have extensive body contact with patient (e.g., rolling the patient)HCP wearing all recommended PPE but not wearing eye protectionIf patient was not wearing a facemask:HCP wearing all recommended PPE (except wearing a facemask instead of a respirator) AND aerosol-generating procedures (see description above) were not performed while HCP presentHCP wearing all recommended PPE but not wearing gown or gloves AND HCP did not have extensive body contact with patient (e.g., rolling the patient) AND aerosol-generating procedures (description above) not performed while HCP presentMedium Risk If patient was wearing a facemask:HCP wearing all recommended PPE but not wearing gown or gloves AND HCP had extensive body contact with the patient (e.g., rolling the patient)HCP not wearing facemask or respiratorHCP not wearing any PPEMedium Risk (cont.)If patient was not wearing a facemask:HCP wearing all recommended PPE (except wearing a facemask instead of a respirator) AND an aerosol-generating procedure (see description above) performed while HCP presentHCP wearing all recommended PPE but not wearing gown or gloves AND HCP had extensive body contact with the patient (e.g., rolling the patient) OR an aerosol-generating procedure (see description above) performed while HCP presentHCP wearing all recommended PPE but not wearing eye protection AND aerosol-generating procedures (see description above) were not performed while HCP presentHigh risk If patient was not wearing a facemask:HCP wearing all recommended PPE but not wearing eye protection AND an aerosol-generating procedure (see description above) performed while HCP presentHCP wearing all recommended PPE but not wearing a facemask or respiratorHCP not wearing any PPECoworker ContactRisk levelRisk level is defined by any of the following situations involving COWORKER contact.No Identifiable RiskInteractions with COVID-19 positive HCW that don’t meet high, medium, or low-risk conditions, such as walking by the COVID-19 positive HCW or staying briefly (<10 minutes) in the same roomLow RiskPresent in the same indoor environment but not within 6 feet for ≥10 minutesClose contact (<6 feet) with the COVID-19 positive HCW for prolonged period (≥10 minutes) while both HCW are wearing facemasks OR while only the positive HCW is wearing a facemask Medium RiskClose contact (<6 feet) with the COVID-19 positive HCW for prolonged period (≥10 minutes) while neither HCW is wearing facemaskClose contact (<6 feet) with the COVID-19 positive HCW for prolonged period (≥10 minutes) while positive HCW is not wearing facemask Direct contact with infectious secretions of a COVID-19 positive person (e.g., being coughed on)High RiskThere are no HCW-HCW exposures considered to be high-riskInstructions for Monitored PersonsLow-Risk CategoryBecause you had a low-risk exposure to a person infected with COVID-19 within the past 14 days, CDC has determined that you should perform self-monitoring until 14 days after the last potential exposure. You are NOT restricted from work. However, each day that you have contact with the infected patient, your exposures will be reassessed, and the monitoring period will begin again. This means that as long as you are not having any symptoms, you are not “in quarantine.” Non-work activities should be guided by current restrictions on social gatherings and state-level recommendations to restrict public movement. You must stay in contact with either MDH or your employer during the self-monitoring period. Please keep track of your activities and people with whom you have close contact, just in case the information may be needed if you develop symptoms. This information can be written down where you keep track of your temperature readings and any symptoms.Understand/AgreeConcerns noted: ____________________________________________________You should remain alert for respiratory symptoms consistent with COVID-19 infection including cough, shortness of breath, and sore throat. Please take your temperature twice daily—each morning and evening around the same time. Your thermometer is FOR YOUR USE ONLY. Do not share it with others in your household. Label it with your name.If you develop fever (measured temperature ≥100.0 F or subjective fever) OR respiratory symptoms, you must immediately self-isolate (separate yourself from others) and promptly notify occupational/employee health at your healthcare facility.If you are experiencing a medical emergency, please call 911 and tell the dispatcher that you recently had exposure to a confirmed COVID-19 case and are being monitored by public health, so that they can take precautions. Also tell the emergency responders this when they arrive. You can call us if you have questions or concerns about the monitoring process. At the end of this call I will provide you with phone numbers including one that will be answered 24/7.Understand/AgreeConcerns noted: ____________________________________________________5106390-149678LOW00LOWThe following are good everyday preventive actions to take.Wash your hands often with soap and water for at least 20 seconds, especially after using the bathroom, before eating, and after blowing your nose, coughing, or sneezing.If soap and water are not readily available, use an alcohol-based hand sanitizer with at least 60% alcohol. Always wash hands with soap and water if hands are visibly dirty. Avoid touching your eyes, nose, and mouth with unwashed hands.Avoid close contact with people who are sick.Cover your cough or sneeze with a tissue, then discard in a lined trash can.Clean and disinfect frequently touched objects and surfaces using a regular household cleaning spray or wipe. Understand/AgreeWe will send you a fact sheet by email that explains self-monitoring of your health during the 14 day monitoring period.Understand/AgreeYou can call us at any time during the monitoring period. As we discussed you should call occupational/employee health at your healthcare facility or MDH if you notice new symptoms. You can also call us about any other concerns that come up during the monitoring period.Contact us at 651-201-5935 (Weekdays, 8am–8pm, Weekends, 10am–6pm) or 651-334-8102 at other times. When you call say that you are a health care worker being monitored. Understand/AgreeINTERVIEWER: Send/email a copy of the recommendations (Fact Sheet Version). Ensure all information needed is on the face sheet. 5035138150867LOW00LOWMedium or High-Risk CategoryBecause you had a medium or high-risk exposure to a person infected with COVID-19 in the past 14 days, CDC has determined you should have active monitoring with public health supervision.This involves two parts. The first involves a VOLUNTARY QUARANTINE in your home, which will last 14 days past last exposure. We are asking you to voluntarily comply with this quarantine. If you do not agree to do so, we may seek a legally enforceable order to quarantine you. The second involves self-monitoring of health under public health supervision. Both of these measures should continue through 14 days after your last contact with a patient infected with COVID-19.I will go over the first part, voluntary quarantine. Then I will discuss active health monitoring.You should not leave your home at all during the monitoring period, except to seek medical care after checking in with public health first. Understand/AgreeSchool/Daycare information: __________________________________________________Minnesota state law provides employment protections for a person who is staying away from work due to a health department recommendation for themselves or if they staying away from work to care for a minor or a disabled/vulnerable adult whom is staying away from work due to a health department recommendation. We can provide a letter for you if you need it. Would you like a letter?Letter neededNOTE: If they need a letter, please ask them to provide you details on how to get them the letter. It is probably easiest for MDH to write a To Whom It May Concern letter and provide it to the person via email to give to their workplace.MDH recommends that you, and other workers with medium or high risk, stay out of work for 14 days. If employers have exhausted all staffing options, they may ask employees without any symptoms to work during the 14-day exclusion period. It is your right to make the choice to return to work if you do not have symptoms. If you were to return to work, you must wear a mask at the worksite. You must keep the mask on the entire time when providing care to a patient or are within 6 feet of any other person in the facility.We want to ensure this is clear. Please tell me your understanding of this information. Understand/Agree4593946360782MEDIUM / HIGH00MEDIUM / HIGHBecause you are considered in a medium or high-risk category by CDC, you must have daily communication with public health so that you can be monitored for fever, cough, sore throat, or difficulty breathing. If you develop fever (measured temperature ≥100.0 F or subjective fever) OR respiratory symptoms, you must immediately self-isolate (separate yourself from others) and promptly notify occupational/employee health at your healthcare facility.Take your temperature each morning and evening around the same time. Record the exact temperature reading. We can email you a temperature log sheet if you would like. Your thermometer is FOR YOUR USE ONLY. Do not share it with others in your household. Label it with your name.MDH will send you an email survey every morning to record your current health status. If you do not respond by 2:00 pm CST, we will call to speak with you. Temperature log neededIf you start feeling ill, isolate yourself at home right away. Promptly notify MDH and the employee health contact at your healthcare facility.Understand/AgreeIf you develop a fever, cough, sore throat, or difficulty breathing, or if you have any other concerns, notify your supervisor, stay home from work and please notify us. If you need to seek medical care, phone the facility ahead to let them know that you are coming and that you are under monitoring for confirmed COVID-19 exposure. This will allow them to use appropriate protective equipment and minimize potential exposure to others. If you experience medical emergency, please call 911 and tell the dispatcher that you recently had contact with a COVID-19 patient and are being monitored by public health, so that they can take precautions. Also tell the emergency responders this when they arrive. Avoid using public transportation, taxis, ride shares like Lyft and Uber, even when seeking medical care. If at all possible we would like you to notify us if symptoms develop and you feel like you need to seek medical care but do not have a private vehicleUnderstand/AgreeThe following are good everyday preventive actions to take.4411066625094MEDIUM / HIGH00MEDIUM / HIGHWash your hands often with soap and water for at least 20 seconds, especially after using the bathroom, before eating, and after blowing your nose, coughing, or sneezing.If soap and water are not readily available, use an alcohol-based hand sanitizer with at least 60% alcohol. Always wash hands with soap and water if hands are visibly dirty. Avoid touching your eyes, nose, and mouth with unwashed hands.Avoid close contact with people who are sick.Cover your cough or sneeze with a tissue, then discard in a lined trash can.Clean and disinfect frequently touched objects and surfaces using a regular household cleaning spray or wipe. Understand/AgreeWe will need to check in with you every day to see how you are doing. To do this, we will send you an email each day reminding you of the need to take your temperature, monitor yourself for symptoms, limit contact with others, and how to contact us if you need assistance or have symptoms. Please reply using the link in the email that you received and read the email each day. If you do not respond by 2 pm CST of initial email, we will call to speak with you. We will email you to let you know that your public health monitoring has ended. Understand/AgreeEmail address: _____________________________________You can call us during the monitoring period about symptoms or any other questions or concerns that come up, including challenges in obtaining essential items where you are staying. Contact us at 651-201-5935 (Weekdays, 8am–8pm, Weekends, 10am–6pm) or 651-334-8102 at other times. When you call say that you are a health care worker being monitored. Understand/AgreeNOTE: Review and ensure you have documented info needed for monitoring. Tell them you would like to send them the recommendations we made in writing (email Fact Sheet Version of script). Do you have any questions now?Concerns noted: ____________________________________________________________4601210512216MEDIUM / HIGH00MEDIUM / HIGHINTERVIEWER: Ensure all information needed is on the face sheet. Give letter request to appropriate person. ................
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