COVID Risk Assessment Tool - Workplace Exposure

• Conducted on

  Date

• Prepared by

• Location
  Address

Section 1. Occupational Information

• NOTE TO INTERVIEWER: The questions in Sections 1–4 refer to the 14 days before the date of first symptom onset. If asymptomatic or if the date of first symptom onset is unknown, the questions can refer to 14 days before the interviewee’s first positive test sample was collected. To guide these questions, record the following dates:

• 1. During the 14-day period, did you work outside of your home?<br>(Note: If there is a single workplace involved, this question can be changed to ask if the person worked at a specific facility.)

  Yes

  No

• 2. If you were employed at any time during the 14-day period, when was the last day you worked outside your home?

  Date

• 3. During the 14-day period, what kind of work did you do?

• 4. During the 14-day period, what kind of business or industry did you work in? (for example, elementary school, clothing manufacturing, restaurant)

• 5. During the 14-day period, what was the name of your employer or business?

• 6. During the 14-day period, which of the following best describes you? (Note: If information about a specific workplace is known before the interviews, this question may be omitted, or answer choices can be adapted.)

  Select I am a regular, permanent employee, paid by the company I work for (standard work arrangement) I am paid by a temporary agency I am paid by a contractor I am a self-employed business owner I work as an independent contractor, independent consultant, or freelance worker I work in some other work arrangement

  • I am a regular, permanent employee, paid by the company I work for (standard work arrangement)
  • I am paid by a temporary agency
  • I am paid by a contractor
  • I am a self-employed business owner
  • I work as an independent contractor, independent consultant, or freelance worker
  • I work in some other work arrangement

• Specify

• 7. During the 14-day period, approximately how many people worked at this location?

  Select 1 employee (just you) 2-9 employees 10-24 employees 25-49 employees 50-99 employees 100-249 employees 250-499 employees 500-999 employees 1000 employees or more Don't know

  • 1 employee (just you)
  • 2-9 employees
  • 10-24 employees
  • 25-49 employees
  • 50-99 employees
  • 100-249 employees
  • 250-499 employees
  • 500-999 employees
  • 1000 employees or more
  • Don't know

• 8. During the 14-day period, which shift did you work? (Note: If information about a specific workplace is known before the interviews, this question may be omitted, or answer choices can be adapted. For example, shifts may be referred to as A, B, C, or shift 1, 2, 3.)

  Select Regular daytime schedule (e.g., first shift) Regular evening shift (e.g., second shift) Regular night shift (e.g., third or overnight shift) Rotating shift (e.g., works on different shifts on different days) Other

  • Regular daytime schedule (e.g., first shift)
  • Regular evening shift (e.g., second shift)
  • Regular night shift (e.g., third or overnight shift)
  • Rotating shift (e.g., works on different shifts on different days)
  • Other

• Specify

• 9. During the 14-day period, how many shifts did you work?

• 10. During the 14-day period, how many hours did you work each shift?

• 11. During the 14-day period, what type of transportation did you use to get to work? (Select all that apply)

  Select Bus Rideshare (e.g., Uber/Lyft)/taxi Private car Train/subway Carpool/van Walk/bike Other Don’t know

  • Bus
  • Rideshare (e.g., Uber/Lyft)/taxi
  • Private car
  • Train/subway
  • Carpool/van
  • Walk/bike
  • Other
  • Don’t know

• Specify

• 12. If you shared a ride either in a bus, train/subway, car, or other type vehicle,

  Yes

  No

• 12a. Were you able to physically distance yourself from others in the same vehicle by at least 6 feet?

  Yes

  No

• 12b. Did you wear a cloth face covering that covered your nose and mouth? Yes No

  Yes

  No

• 12c. Did everyone else in the vehicle wear a cloth face covering or face mask that covered their nose and mouth?

  Yes

  No

• 13. During the 14-day period, what was your job title? (Note: this question can be a free text field, or a list can be customized depending on job titles at a specific facility; this question is more specific than question 3, which asks about type of work [i.e., occupation].)Obtain the most recent proportion of confirmed or probable cases for the local community of the worksite:

• 14. During the 14-day period, what department were you assigned to? (select all that apply) (Note: If information about a specific workplace is known before the interviews, this question may be omitted, or answer choices can be customized depending on the facility.)

  Select Reception area Production area Break area

  • Reception area
  • Production area
  • Break area

• 15. During the 14-day period, what areas of the facility did you spend most of your time in? (select all that apply) (Note: This list should be customized depending on the facility; the following are examples.)

  Select Harvest (could also be referred to as hot) Fabrication (could also be referred to as cold) Administrative office Other

  • Harvest (could also be referred to as hot)
  • Fabrication (could also be referred to as cold)
  • Administrative office
  • Other

• Specify

• 6. During the 14-day period, how often did you wear a cloth face covering or face mask (for example, a surgical mask) while at work for the purposes of source control (to contain your respiratory secretions) not as personal protective equipment?

  Always

  Sometimes

  Rarely

  Never

  Don’t know

• 17. During the 14-day period, how often was everyone else in the facility (e.g., co-workers, customers/clients, visitors) wearing a cloth face covering or face mask (for example, a surgical mask) while at work?

  Always

  Sometimes

  Rarely

  Never

  Don’t know

• 18. During the 14-day period, did you use any personal protective equipment (PPE)?<br>(Note: If information about a specific workplace is known before the interviews, the types of PPE included here can be adapted. Images of the PPE<br>used at the workplace might be helpful.)

  Yes

  No

• 19. Why did you use PPE?

  Select For protection from a pre-COVID-19 pandemic workplace chemical, particulate, or biological hazard For protection from COVID-19

  • For protection from a pre-COVID-19 pandemic workplace chemical, particulate, or biological hazard
  • For protection from COVID-19

Did you use...?

• Gloves:

  Yes

  No

  Don't Know

• what kind? (Note: If information about a specific workplace is known before the interviews, the types of PPE included here can be adapted.)

• how often did you use this type of PPE?

  Always

  Sometimes

  Rarely

  Never

  Don’t know

• Material (e.g., nitrile)

• Purpose (e.g., cut resistant)

• Goggles/safety glasses:

  Yes

  No

  Don't Know

• how often did you use this type of PPE?

  Always

  Sometimes

  Rarely

  Never

  Don’t know

• Face shield:

  Yes

  No

  Don't Know

• how often did you use this type of PPE?

  Always

  Sometimes

  Rarely

  Never

  Don’t know

• Respirator :

  Yes

  No

  Don't Know

• what kind? (Note: an infographic with pictures of different types of respiratory protection can be found at https://www.cdc.gov/niosh/npptl/pdfs/RespProtectionTypes-508.pdf)

  Select Disposable Filtering Facepiece Respirator (e.g., N95, P100, etc.) Elastomeric Half Facepiece Respirator (reusable with changeable cartridges) Elastomeric Full Facepiece Respirator (reusable with changeable cartridges) Powered-Air Purifying Respirator or PAPR

  • Disposable Filtering Facepiece Respirator (e.g., N95, P100, etc.)
  • Elastomeric Half Facepiece Respirator (reusable with changeable cartridges)
  • Elastomeric Full Facepiece Respirator (reusable with changeable cartridges)
  • Powered-Air Purifying Respirator or PAPR

• did you receive training on how to use respirators properly?

  Yes

  No

  Don't Know

• If you used a disposable respirator, were you required to re-use it?

  Yes

  No

  Don't Know

• If a disposable respirator was re-used, was it decontaminated first?

  Yes

  No

  Don't Know

• specify method

• how often did you use this type of PPE?

  Always

  Sometimes

  Rarely

  Never

  Don’t know

• Smock/Coveralls/Other type of body covering

  Yes

  No

  Don't Know

• what type? (select all that apply)

  Select Tyvek or equivalent Cloth (washable) Disposable

  • Tyvek or equivalent
  • Cloth (washable)
  • Disposable

• how often did you use this type of PPE?

  Always

  Sometimes

  Rarely

  Never

  Don’t know

• Do you wear any other PPE while at work?

  Yes

  No

  Don't Know

• please specify

• how often did you use this type of PPE?

  Always

  Sometimes

  Rarely

  Never

  Don’t know

• 20. Did any employees diagnosed with COVID-19 come to the worksite within 48 hours before their symptoms began? Or, if the case didn’t show any symptoms, 48 hours prior to receiving a positive test result?

  Yes

  No

  Don't Know

• 20a. What kind of work did you do? Please list for all other jobs. (for example, registered nurse, janitor, cashier, auto mechanic) Please list for all other jobs

• 20b. what kind of business or industry did you work in? Please list for all other jobs.<br>(for example, hospital, elementary school, clothing manufacturing, restaurant)

  Always

  Sometimes

  Rarely

  Never

  Don’t know

Section 2: Facility Information

• NOTE TO INTERVIEWER: For the following questions, close contact means being within 6 feet for a total of 15 minutes or more. Six feet (2 meters) is about the length of a twin or full-size mattress.

• 1. During the 14-day period, did you have close contact with a person or persons who were visibly ill (or had probable or confirmed COVID-19) at your workplace?<br>(Note: Consider adding definition/symptoms for ‘visibly ill’)

  Yes

  No

  Don't Know

• 1a. What was the first day you had close contact with a person who was visibly ill (or had probable or confirmed COVID-19)?

  Date

• 1b. What was the last day you had close contact a person who was visibly ill (or had probable or confirmed COVID-19)?

  Date

• 1c. Where in the workplace did you have close contact with a person or persons who were visibly ill (or had probable or confirmed COVID-19)? (select all that apply) (Note: Answer choices can be customized depending on the facility.)

  Select When entering or exiting your workplace In a locker room or restroom In the production area In break areas or cafeteria In an on-site occupational health clinic Getting to or from work In another location

  • When entering or exiting your workplace
  • In a locker room or restroom
  • In the production area
  • In break areas or cafeteria
  • In an on-site occupational health clinic
  • Getting to or from work
  • In another location

• Specify

• When you had close contact with a person or persons who were visibly ill (or had probable or confirmed COVID-19) at the workplace, was that person’s/those persons’ nose and mouth covered with a cloth face covering or a face mask?

  Always

  Sometimes

  Rarely

  Never

  Don’t know

12. During the 14-day period, were any of the following done at your workplace?

• (Notes: This list can be customized depending on work setting; These questions do not need to be included in worker interviews if a workplace assessment
  has been performed.)

• Activities in the workplace during the 14-day period

• All employees were screened before entering the workplace

  Yes

  No

  Don't Know

• was it for all or some of the 14 days?

  All some don't know

  Some

  Don't Know

• Work practices made it possible to remain 6 feet (2 meters) away from other people

  Yes

  No

  Don't Know

• was it for all or some of the 14 days?

  All some don't know

  Some

  Don't Know

• Barriers were in place between workstations

  Yes

  No

  Don't Know

• was it for all or some of the 14 days?

  All some don't know

  Some

  Don't Know

• Workers were using personal cooling fans

  Yes

  No

  Don't Know

• was it for all or some of the 14 days?

  All some don't know

  Some

  Don't Know

• It was possible to remain 6 feet (2 meters) away from other people in non-work areas, including:

• Entrances and exits

  Yes

  No

  Don't Know

• was it for all or some of the 14 days?

  All some don't know

  Some

  Don't Know

• Clock in/out areas

  Yes

  No

  Don't Know

• was it for all or some of the 14 days?

  All some don't know

  Some

  Don't Know

• Uniform/equipment pickup areas

  Yes

  No

  Don't Know

• was it for all or some of the 14 days?

  All some don't know

  Some

  Don't Know

• Break areas

  Yes

  No

  Don't Know

• was it for all or some of the 14 days?

  All some don't know

  Some

  Don't Know

• Break areas

  Yes

  No

  Don't Know

• was it for all or some of the 14 days?

  All some don't know

  Some

  Don't Know

• Break areas

  Yes

  No

  Don't Know

• was it for all or some of the 14 days?

  All some don't know

  Some

  Don't Know

• Break areas

  Yes

  No

  Don't Know

• was it for all or some of the 14 days?

  All some don't know

  Some

  Don't Know

• Hand cleaning supplies (soap and clean water or alcohol-based hand sanitizer) were available in convenient locations

  Yes

  No

  Don't Know

• was it for all or some of the 14 days?

  All some don't know

  Some

  Don't Know

• Leave policies made it possible to stay home when ill

  Yes

  No

  Don't Know

• was it for all or some of the 14 days?

  All some don't know

  Some

  Don't Know

3. Was training and communication provided at work on the following topics?

• (Notes: This list can be customized depending on work setting; These questions do not need to be included in worker interviews if a workplace assessment has been performed.)

• Was work training and communication provided on following topics?

• Signs and symptoms of COVID-19

  Yes

  No

  Don't Know

• How COVID-19 is spread

  Yes

  No

  Don't Know

• What to do if you are sick before or at work

  Yes

  No

  Don't Know

• Hand hygiene

  Yes

  No

  Don't Know

• How to protect yourself from COVID-19 infection at work

  Yes

  No

  Don't Know

• How to protect yourself from COVID-19 infection outside of work

  Yes

  No

  Don't Know

• How to maintain social distancing (maintaining distance of at least 6 feet

  Yes

  No

  Don't Know

• between co-workers, customers, etc.) at work

  Yes

  No

  Don't Know

• How to safely put on and take off personal protective equipment (PPE)

  Yes

  No

  Don't Know

• How to safely put on and take face coverings

  Yes

  No

  Don't Know

• Sick leave policy

  Yes

  No

  Don't Know

Section 3: Alternative Fromat for PPE Questions

• Was any personal protective equipment (PPE) or other type of personal barrier used for any work activities/tasks?

  Yes

  No

  Unknown

Task1 (T1):

• Disposable gloves Used in task?

  Yes

  No

• did the use of PPE/Barrier change due to COVID-19?

  Select No change, this was already routinely used and remained available Yes, this was added due to COVID-19 Yes, this was in routine use before, but availability decreased due to COVID-19availability decreased due to COVID-19

  • No change, this was already routinely used and remained available
  • Yes, this was added due to COVID-19
  • Yes, this was in routine use before, but availability decreased due to COVID-19availability decreased due to COVID-19

• Surgical/face mask; describe: Used in task?

  Yes

  No

• did the use of PPE/Barrier change due to COVID-19?

  Select No change, this was already routinely used and remained available Yes, this was added due to COVID-19 Yes, this was in routine use before, but availability decreased due to COVID-19availability decreased due to COVID-19

  • No change, this was already routinely used and remained available
  • Yes, this was added due to COVID-19
  • Yes, this was in routine use before, but availability decreased due to COVID-19availability decreased due to COVID-19

• Goggles/safety glasses; describe: Used in task?

  Yes

  No

• did the use of PPE/Barrier change due to COVID-19?

  Select No change, this was already routinely used and remained available Yes, this was added due to COVID-19 Yes, this was in routine use before, but availability decreased due to COVID-19availability decreased due to COVID-19

  • No change, this was already routinely used and remained available
  • Yes, this was added due to COVID-19
  • Yes, this was in routine use before, but availability decreased due to COVID-19availability decreased due to COVID-19

• Face shield Used in task?

  Yes

  No

• did the use of PPE/Barrier change due to COVID-19?

  Select No change, this was already routinely used and remained available Yes, this was added due to COVID-19 Yes, this was in routine use before, but availability decreased due to COVID-19availability decreased due to COVID-19

  • No change, this was already routinely used and remained available
  • Yes, this was added due to COVID-19
  • Yes, this was in routine use before, but availability decreased due to COVID-19availability decreased due to COVID-19

• Respirator* Used in task?

  Yes

  No

• did the use of PPE/Barrier change due to COVID-19?

  Select No change, this was already routinely used and remained available Yes, this was added due to COVID-19 Yes, this was in routine use before, but availability decreased due to COVID-19availability decreased due to COVID-19

  • No change, this was already routinely used and remained available
  • Yes, this was added due to COVID-19
  • Yes, this was in routine use before, but availability decreased due to COVID-19availability decreased due to COVID-19

• Respirator*

  Select disposable filtering face piece, e.g., N95; elastomeric half face, elastomeric full face, PAPR

  • disposable filtering face piece, e.g., N95;
  • elastomeric half face,
  • elastomeric full face,
  • PAPR

• Was this the same type (model/ size) the worker was fit tested on? (does not apply to PAPR)

  Yes

  No

• Gown / Coveralls Used in task?

  Yes

  No

• did the use of PPE/Barrier change due to COVID-19?

  Select No change, this was already routinely used and remained available Yes, this was added due to COVID-19 Yes, this was in routine use before, but availability decreased due to COVID-19availability decreased due to COVID-19

  • No change, this was already routinely used and remained available
  • Yes, this was added due to COVID-19
  • Yes, this was in routine use before, but availability decreased due to COVID-19availability decreased due to COVID-19

• Check if:

  Cloth (washable)

  Disposable

• Other

• did the use of PPE/Barrier change due to COVID-19?

  Select No change, this was already routinely used and remained available Yes, this was added due to COVID-19 Yes, this was in routine use before, but availability decreased due to COVID-19availability decreased due to COVID-19

  • No change, this was already routinely used and remained available
  • Yes, this was added due to COVID-19
  • Yes, this was in routine use before, but availability decreased due to COVID-19availability decreased due to COVID-19

Section 4: Community Exposures

• NOTE TO INTERVIEWER: Questions from this section would only be used if this information is unavailable from a case report form or other available records.

• For the following questions, close contact is being within 6 feet for a total of 15 minutes or more. Six feet (2 meters) is about the length of a twin or full-size mattress.

1. During the 14-day period, did you…

• …attend a gathering of >50 people (e.g., religious event, wedding, party, dance, concert, banquet, festival, sports event, funeral, or other event)?

  Yes

  No

  Don't Know

• …attend a gathering of >10 but ≤50 people (e.g., religious event, wedding, party, funeral, or other event)?

  Yes

  No

  Don't Know

• …use public or shared transportation (bus, train, airplane, Uber/Lyft, taxi, carpooling) to get to and from places other than work?

  Yes

  No

  Don't Know

• … go to school or daycare in-person?

  Yes

  No

  Don't Know

• …have a household member who went to school or daycare in-person?

  Yes

  No

  Don't Know

• …have close contact with a sick person who had close contact with a COVID-19 patient (i.e., secondary contact with a person with confirmed COVID-19)?

  Yes

  No

  Don't Know

• …have close contact with a person who had traveled in the previous 2 weeks?

  Yes

  No

  Don't Know

• 2. During the 14-day period, did you have close contact with a person or persons who were visibly ill (or had probable or confirmed COVID-19) outside of the workplace?

  Yes

  No

  Don't Know

• 2a. When was the first day you had close contact with a person or persons who were visibly ill (or had probable or confirmed COVID-19)?

  Date

• 2b. When was the last day you had close contact with a person or persons who were visibly ill (or had probable or confirmed COVID-19)?

  Date

• 2c. How do you know this person(s)? (select all that apply)

  Select Household member/intimate partner Family (who does not live with you) Friend (non-household member) Co-worker Contact only – no relationship Other

  • Household member/intimate partner
  • Family (who does not live with you)
  • Friend (non-household member)
  • Co-worker
  • Contact only – no relationship
  • Other

• Specify

• 2d. Where did you have close contact with this person(s)? (select all that apply)

  Select Household Daycare Daycare School/University Public Transportation/Rideshare/Carpooling Hotel Healthcare setting Other

  • Household Daycare
  • Daycare
  • School/University
  • Public Transportation/Rideshare/Carpooling
  • Hotel
  • Healthcare setting
  • Other

• Specify

• 3. During the 14-day period, did you travel away from home (out of the county, state, or country)?

  Yes - Domestic Travel

  Yes - international travel

  No

  Don't know

• Where did you go?

• How did you get there?

  Select Airplane Train Bus Private car Taxi/Rideshare Other

  • Airplane
  • Train
  • Bus
  • Private car
  • Taxi/Rideshare
  • Other

• Specify

• specify destination(s)

• Where did you go?

• How did you get there?

  Select Airplane Train Bus Private car Taxi/Rideshare Other

  • Airplane
  • Train
  • Bus
  • Private car
  • Taxi/Rideshare
  • Other

• Specify

• 4. What was your living situation?

  Select Lived in my own home/apartment in the same community as the facility in which I work Lived in my own home/apartment in another community Lived in temporary housing while I was working Did not have any reliable housing during this time Other

  • Lived in my own home/apartment in the same community as the facility in which I work
  • Lived in my own home/apartment in another community
  • Lived in temporary housing while I was working
  • Did not have any reliable housing during this time
  • Other

• specify

• 5. How many other people lived with you?

• 6. What type of housing (select one) did you live in?

  Apartment

  Trailer

  House

  Hotel

  Other

• please specify

• 7. Was your housing provided by the employer?

  Yes

  No

• 8. How many bedrooms were there in your home?

• 9. How many bathrooms were there in your home?

• 10. If other persons lived in the household, did they work outside of the home?

  Yes

  No

• 11. where did they work (select all that apply)?

  Select Same place as you Long-term care facility Hospital Other healthcare setting (including home health care) School Day care Corrections facility Food processing facility Other type of factory or warehouse Farming Retail (store) Mobile job (e.g., driver, package deliverer) Other

  • Same place as you
  • Long-term care facility
  • Hospital
  • Other healthcare setting (including home health care)
  • School
  • Day care
  • Corrections facility
  • Food processing facility
  • Other type of factory or warehouse
  • Farming
  • Retail (store)
  • Mobile job (e.g., driver, package deliverer)
  • Other

• please specify

Section 5: Ability to Quarantine and Risk to Other Household Members

• 1. What is the age of the eldest person in your household? (years)

• 2. What is the age of the youngest person in your household?

• 3. Are there any people living in your household with any of the following health conditions? (check all that apply)

  Select Diabetes Obesity Heart disease Chronic respiratory disease (e.g., asthma, COPD, emphysema) Cancer Kidney disease Pregnancy Other chronic health condition

  • Diabetes
  • Obesity
  • Heart disease
  • Chronic respiratory disease (e.g., asthma, COPD, emphysema)
  • Cancer
  • Kidney disease
  • Pregnancy
  • Other chronic health condition

• please specify

• 4. Are you able to maintain at least 6 feet of distance from other persons in the home?

  Yes

  No

• 5. If you were given the option of isolating yourself outside of the home to prevent transmission to other members of the household, would you take that option?

  Yes

  No

• why not?

  Yes

  No

• What would make it possible to allow you to isolate in a location outside the home?

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