family-centered residential facility guest health ... · family-centered residential facility guest...

Family-centered residential facility

Guest health screening questions

Please answer YES or NO to all of the questions below.

HAVE YOU HAD ANY OF THE FOLLOWING:

YES NO Feverhigherthan100.4°F(38.0°C)inthepast2days?

YES NO Vomitinginthepast2days?

YES NO Stiffneckorheadachewithafeverinthepast2days?

YES NO Diarrheainthepast2days?

YES NO Currentskinlesionsthatare“weepy”(fluidorpus-filled)?

YES NO ANYcurrentskinrash?

YES NO Currentcoldorflusymptoms(runnynose,cough,congestion)?

YES NO ExposuretoTuberculosis(TB)inthepast2months?

YES NO Exposuretoanyofthefollowingwithinthepast3weeks:

Chickenpox

Householdmemberwithheadlice

Measles

Mumps

WhoopingCough

Contact the Program Manager to discuss any “yes” answer above, prior to allowing entry.

CHICKENPOX STATUS:

YES NO Haveyouhadchickenpoxorshinglesbefore?

YES NO Haveyoubeenvaccinatedagainstchickenpox(varicella)?

SHEArepresentsmorethan2,000physiciansandhealthcareprofessionalswithexpertiseinhealthcareepidemiologyandinfectionprevention.SHEA’smissionistopreventandcontrolhealthcare-associatedinfectionsandtranslateknowledgeintoeffectivepolicyandpracticetoimprovepatientcareandhealthcareworkersafety.www.shea-online.org

ThesematerialsaredevelopedinpartnershipwithandfundingfromRonaldMcDonaldHouseCharities®,anonprofitorganizationdedicatedtodirectlyimprovingthehealthandwellbeingofchildren.

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Family-centered residential facility

Medical clearance form for epidemiologically significant infections

This form must be completed by a physician or public health department official who is currently involved in the child’s medical care.

Parent/legalguardianname(PRINT)

Pediatricpatient’sname(PRINT)

Pediatricpatient’sdiagnosis(please CIRCLE):

Chickenpox(varicella) Measles Tuberculosis

Ecolicolitis/diarrhea/HUS Mumps Whoopingcough(pertussis)

HepatitisA Salmonellacolitis/diarrhea Other

Herpesinfection Shigellacolitis/diarrhea(HSV-1orHSV-2)

I have reviewed this patient’s records (named above) and determined the exposed family members NOT contagious to other residential facility guests. Please mark as appropriate below:

Familymembershavehistoryofcompleteimmunizationornaturaldisease

immunityagainstthisspecificdisease.

Familymembershavecompletedafullcourseofappropriateantibiotic

exposureprophylaxisagainstthisspecificdisease.

Familymembershavebeenevaluatedandclearedbypublichealthdepartment.

Familymembersarecurrentlynotill,andnotconsideredarisksince

currentlyhealthy.

Physician/public health official (PRINT NAME) Date of evaluation

Physician/public health official (SIGNATURE) Physician/public health official’s contact phone



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Guidance for cleaning up blood and body fluids

Blood and body fluids can spread infections such as hepatitis B, hepatitis C, and HIV. To protect yourself when cleaning up another person’s blood or body fluids:

Avoidskincontactwiththebloodorfluids.

Wearglovestocleanupthebloodorfluids.

Firstblotapoolofbloodorfluidwithadisposablepapertowel.Thenclean

anddisinfectcontaminatedsurfaceswithacleandisposablepapertoweland

adilutebleachsolution(1parthouseholdbleachto9partswater).

Disposeofmaterialsusedtocleanbloodandbodyfluidspillsorcontamination

inasealedplastictrashbag.

Afterremovinggloves,cleanyourhandswithsoapandwateroranalcohol-

basedhandrub.

Ifyourskincomesintocontactwithanotherperson’sbloodorbodyfluids:

Immediatelywashtheexposedskinwithsoapandwater.Immediatelyconsult

withahealthcareprovider.



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Respiratory etiquette:

What to do if you have a cough or cold

Respiratory infections are especially dangerous for young children, the elderly and patients with chronic health conditions.

IF YOU ARE SICK WITH A COUGH OR COLD:

Coveryournoseandmouthwithatissueeverytimeyoucoughorsneeze,

andthrowtheusedtissueawaypromptly.

Ifyoudonothaveatissue,sneezeorcoughintoyourelboworsleeve.

Aftercoughingorsneezing,alwayscleanyourhandswithsoapandwater

oranalcohol-basedhandrub.

Ifyouhavearunnynoseandcough,stayinyourprivateroomandaway

fromothersuntilyouarebetter.

Donotshareeatingutensils,drinkingglasses,towelsorpersonalitems.

TO STAY HEALTHY:

Cleanyourhandsoftenwithsoapandwateroranalcohol-basedhandrub.

Avoidtouchingyoureyes,noseormouth.

Avoidclosecontactwithpeoplewhoareill.

Getvaccinated.Influenzaandpertussisvaccinationscanpreventyoufrom

gettingseriousrespiratoryillnesses.Gettingvaccinatedmayalsoprotectyour

childrenfrominfluenzaandpertussis.



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Hand hygiene:

Hand washing and using waterless alcohol-based hand rubs

Hand hygiene is the best way to prevent the spread of germs.

CLEAN YOUR HANDS:

Beforeandaftercaringforsomeonewhoissick.

Afterremovinggloves.

Before,duringandafterpreparingfood.

Beforeeating.

Beforeandaftertreatingacutorwound.

Beforeandaftertouchinganinvasivedeviceandgivingmedicine

toanotherperson.

Afterusingatoilet.

Afterchangingdiapersorcleaningupachildwhohasusedthetoilet.

Afterblowingyournose,coughing,orsneezing.

Beforeandaftertouchingananimal.

Afterhandlinganimalwaste.

Aftertouchinggarbage.



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NOTE: Need a timer? Scrub your hands while humming the “Happy Birthday” song from beginning to end twice or while singing the ABCs once. Hands may also be air-dried.

Hand hygiene:

Technique with soap and water

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Notes: Need a timer? Scrub your hands while humming the "Happy Birthday" song from beginning to end twice or while singing the ABCs once. Hands may also be air-dried.

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Notes: Need a timer? Scrub your hands while humming the "Happy Birthday" song from beginning to end twice or while singing the ABCs once. Hands may also be air-dried.



WHOGuidelinesonHandHygieneinHealthCarehttp://whqlibdoc.who.int/publications/2009/9789241597906_eng.pdf,accessedAugust2013

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NOTE: Always use soap and water instead of alcohol-based hand rub after using the toilet or when hands are visibly dirty or soiled with blood or other bodily fluids. Soap and water is also preferred when taking care of a child who has diarrhea caused by Clostridium difficile (“C diff”) or norovirus.

Hand hygiene:

Technique with alcohol-based formulation



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Notes: Always use soap and water instead of alcohol-based hand rub after using the toilet or when hands are visibly dirty or soiled with blood or other bodily fluids. Soap and water is also preferred when taking care of a child who has diarrhea caused by Clostridium difficile (“C diff”) or norovirus.

http://whqlibdoc.who.int/publications/2009/9789241597906_eng.pdf

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WHOGuidelinesonHandHygieneinHealthCarehttp://whqlibdoc.who.int/publications/2009/9789241597906_eng.pdf,accessedAugust2013

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