Pandemic Influenza Plan - Questar III

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Appendix 8-H NYSDOH Model <strong>Influenza</strong> Voluntary Home Isolation Agreement I have been informed that I have been diagnosed as a suspect or probable case of influenza, a communicable disease dangerous to the public health, and that unless precautions are taken, others may contract this infection from me. The local health department (LHD) and its commissioner, is required to protect the public from the danger of such communicable diseases by Public Health Law §§ 308 and 324, Public Health Law Art. 21, and 10 NYCRR Part 2. In order to prevent the spread of this virus the LHD has provided me with the following information, advised me of the need to comply with the following instructions and I hereby agree to the following: I shall remain in home isolation for a period of X days without fever, respiratory symptoms (such as cough, shortness of breath, or difficulty breathing) or sore throat. I shall be isolated at the following location which shall hereinafter be referred to as “home”: Street address: ________________________________________________________ City: __________________ County: ____________________ Zip: ______________ Telephone: (_____) _______-_______ I have been educated about the disease, the reasons for isolation in the home, and the length of time I can expect to be confined to the home. I shall limit all activities and interaction with all other persons living outside the home. I shall not go to school, a house of worship, work, out-of-home day care, stores or other public areas. I shall not leave the home for any reason unless first authorized to do so by the LHD. I understand that only those persons authorized by the LHD may enter my home during the period of my isolation. Those who enter the home without prior authorization from the LHD may be subject to isolation or quarantine themselves. I agree to notify friends and relatives that they shall not visit the home until further notice. I shall use a separate bed and, if possible, a separate bedroom. I shall wear a surgical mask when in the same room with non-infected persons. If I cannot wear a surgical mask, others in the same room will be asked to wear a surgical mask or respirator. February 7, 2006 3
Appendix 8-H If I am not masked I shall cover my nose and mouth with a disposable tissue when coughing or sneezing. Household waste, including surgical masks and disposable tissues soiled with respiratory secretions, blood, or other body fluids will be disposed of as normal household waste. I will wash my hands with soap and water after all contact with respiratory secretions from coughing or sneezing, blood, and all other body fluids (e.g. urine, feces, wound drainage, etc.). I will educate and encourage other members of my household to do the same. All members of my household will wear gloves on both hands when they have contact with my respiratory secretions (lung or nasal), blood, and all other body fluids (e.g. urine, feces, wound drainage, etc.). Alcohol-based hand hygiene products may be substituted for hand washing with soap and water after removing the gloves, IF the hands are not visibly soiled with respiratory secretions, blood, or other body fluids. Gloves shall not be reused and shall be discarded immediately after removal. My eating and drinking utensils will be washed with hot water and a household dishwashing detergent. Environmental surfaces (e.g. countertops, tables, sinks, etc.) in the kitchen, bathroom, and my bedroom will be cleaned and disinfected with a household disinfectant, such as household bleach or Lysol ® , while wearing gloves, at least daily and when soiled with the respiratory secretions, blood, and other body fluids. My bed linens, towels, and personal clothing shall not be shared with other members of the household. Clothes and linens will be washed in hot soapy water. All members of my household or other close contacts who develop fever or respiratory symptoms will seek medical evaluation. I understand that to prevent transmission of influenza, I should advise members of the household who develop influenza symptoms that they shall call the physician’s office, clinic, or hospital emergency department where they intend to seek care to alert healthcare workers there prior to seeking treatment. I will obtain or request the LHD to provide me and members of my household with surgical masks, gloves, and other items necessary to prevent the spread of influenza (i.e. alcoholbased hand wash). I will arrange or request the LHD to arrange for the delivery of necessary items to my home, including but not limited to, food, clothing, and supplies, during the period of isolation. February 7, 2006 4
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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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Appendix 6-B Mass Clinic Planning O
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Appendix 6-C Vaccine and Antiviral
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Appendix 6-C 1. Request Phase The r
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Appendix 6-C 3. Receipt and Sign-of
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Appendix 6-C • Work with local he
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Section 7: Antiviral Medication Pro
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Page 277 and 278: Appendix 8-F Definitions: Intervent
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Page 283 and 284: Appendix 8-G Business Pandemic Infl
Page 285 and 286: Appendix 8-G 4. Allocate resources
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Page 291 and 292: Appendix 8-H NYSDOH Model Influenza
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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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Pandemic Influenza Plan - Questar III

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