Pandemic Influenza Plan - Questar III

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Appendix 8-C Contact Record Form Original Patient Serial No: ___________________ Index Case No: ______________________ Name: __________________________________________ Sex: __________ Pregnant: ______ DOB: _______________ Race/Ethnicity: ____________________ Underlying Medical Conditions: ___________________________ ______________________________________________________ Contact Information: Home Address: ____________________________________ ____________________________________ ____________________________________ Work Address: ____________________________________ ____________________________________ ____________________________________ Phone: ____________________________ Cellular Phone: ________________________ Exposure History: First Exposure: _______________ Last Exposure: _______________ Frequency/Duration: __________________ Exposure Ongoing? ___________________ Phone: ____________________________ If HCW, PPE Used: Eye Protection: Y / N Respiratory: Y / N Gown: Y / N Gloves: Y / N Aerosol Generating Procedure? Y/N Describe: _______________________ Type of Exposure: ________________________________________________________ Exposure Timing: ________________________________________________________ Outcome: Date Notified: ________________ Symptoms Present? ____________ If Yes, Date of Onset: __________________ Symptom Type: _____________________ Date of Resolution: ______________ Medical Exam? _______________ If Yes, Date of Exam: __________________ Start of Quarantine: ________________ End of Quarantine: _________________ February 7, 2006 1
Appendix 8-C Administrative Data: Supervisor: ______________________________ Investigating Agency: _____________________ Assigned To: ____________________________ Initiating Agency: ______________ Disposition: _______________ Disposition Date: ____________ Dx. ________________ Dx. Date: __________________ Worker No. ____________ If New Case Enter HIN#: _____________________ Notes: ______________________________________________________________________________ ______________________________________________________________________________ February 7, 2006 2
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February206 Pandemic Plan NewYorkSt
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Introduction Pandemic influenza occ
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example, at this time, it is realis
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Acronyms (cont.) IND IHANS IRB ISHS
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Section 1: Command and Control I. O
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Section 1: Command and Control pers
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February 7, 2006 Appendix 1-A
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Appendix 1-B The Public Health Law
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Appendix 1-B communicable diseases
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Appendix 1-C Management Office or t
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Appendix 1-E Suspension of Public M
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Appendix 1-G A Guide to New York St
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Appendix 1-G health commissioner. P
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Appendix 1-G 8. State Institutions
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Appendix 1-G b. Governor May Invoke
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Appendix 1-G may direct, pursuant t
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Appendix 1-G c. Commissioner of Gen
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Appendix 1-G Designation of emergen
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Appendix 1-G physician’s assistan
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Appendix 1-H Summary of Public Offi
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Section 2: Surveillance and Laborat
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Appendix 2-A • Surveillance Crite
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Appendix 2-A • In New York City,
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NYSDOH Novel Influenza Case Report
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Appendix 2-C to health care provide
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Virus Detection History NYS Lab Num
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Section 3: Healthcare Planning and
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Section 4: Infection Control I. Ove
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Section 4: Infection Control I. Ove
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Section 4: Infection Control A. Bas
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Section 4: Infection Control Drople
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Section 4: Infection Control • Pe
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Section 4: Infection Control o Noti
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Section 4: Infection Control E. Coh
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Section 4: Infection Control If wid
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Section 4: Infection Control • En
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Section 4: Infection Control should
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Section 4: Infection Control Policy
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Section 4: Infection Control o Staf
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Section 4: Infection Control • De
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Section 4: Infection Control • Pr
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Section 4: Infection Control The ma
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Section 4: Infection Control • Up
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Section 4: Infection Control Health
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Appendix 4-A Soiled linen and laund
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Appendix 4-B Respiratory Hygiene/Co
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Section 5: Clinical Guidelines I. O
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Section 5: Clinical Guidelines incu
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Section 5: Clinical Guidelines 1) N
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Section 5: Clinical Guidelines infe
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Section 5: Clinical Guidelines Alth
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Section 5: Clinical Guidelines Infe
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Section 5: Clinical Guidelines •
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Appendix 5-B Clinical Evaluation of
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Appendix 5-C Special Situations and
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Appendix 5-D handling soiled laundr
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DRAFT Appendix 5-E Footnotes to App
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Appendix 5-F February 7, 2006 1
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Appendix 5-F 7. Guidance on the eva
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Appendix 5-H Source: U.S. Departmen
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February 7, 2006 2 Appendix 5-I
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Appendix 5-J Clinical Presentation
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Appendix 5-J diabetes mellitus), re
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Appendix 5-J resistant S. aureus (M
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Appendix 5-K eight patients—all o
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Appendix 5-L Guidelines for Managem
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Appendix 5-L testing should be perf
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Appendix 5-L February 7, 2006 5
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Section 6: Vaccine Procurement, Dis
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Appendix 6-A Vaccine Priority Group
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Page 223 and 224: Appendix 6-C Vaccine and Antiviral
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Page 229 and 230: Appendix 6-C • Work with local he
Page 231 and 232: Section 7: Antiviral Medication Pro
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Page 251 and 252: Appendix 7-B a The drug package ins
Page 253 and 254: Appendix 7-C 7 HCWs in emergency de
Page 255 and 256: Section 8: Travel-Related Disease C
Page 267 and 268: Appendix 8-A Home or Community-Base
Page 269 and 270: Appendix 8-B Contact Identification
Page 271: Appendix 8-B • Determine the time
Page 275 and 276: Appendix 8-D CONTACT DAILY TEMPERAT
Page 277 and 278: Appendix 8-F Definitions: Intervent
Page 279 and 280: Appendix 8-F facility. No specific
Page 281 and 282: Appendix 8-F • Resources Required
Page 283 and 284: Appendix 8-G Business Pandemic Infl
Page 285 and 286: Appendix 8-G 4. Allocate resources
Page 287 and 288: Appendix 8-H CDC guidelines suggest
Page 289 and 290: Appendix 8-H If I am not masked I
Page 291 and 292: Appendix 8-H NYSDOH Model Influenza
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Page 311 and 312: Appendix 9-C New York State Departm
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Page 315 and 316: Appendix 9-C PROTECTIVE MESSAGE MAP
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Page 319 and 320: Appendix 9-C BUSINESS CONTINUITY PR
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Section 10: Training and Education
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Section 10: Training and Education
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Appendix 10-A NYSDOH STAFF PRIVATE
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FACILITY- BASED RNs FACILITY- BASED
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Section 11: Workforce Support I. Ov
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Section 11: Workforce Support Pande
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Section 12: Highly Pathogenic H5N1
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Section 12: H5N1 in Non-Human Anima
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Section 13: Public Health Preparedn
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Appendix 13-A NYSDOH Roles Notified
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Appendix 13-B Notifications sent by
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Appendix 13-B HAN posting is used a
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Appendix 13-B notification system t
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Appendix 13-C Overview of the Healt
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Appendix 13-C • Ongoing surveilla
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Table 1. Summary of HERDS Use To da
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Appendix 13-D Commerce Access and A
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Appendix 13-D Table 3. Organization
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