Table 4.

Sample Prevalence Instrument

Survey questions	Answers
1. Which state is your health care facility located in?	(select one state)
Below is an example of an N95 (courtesy of the OSHA). 2. Have any of your employees used an N95 FFR at least once in the past year, including training exercises or fit testing?	Yes No
3. Approximately how many of your employees have used an N95 FFR in the past year, including training exercises or fit testing?	10 or less 11-100 101-500 More than 500
4. What are the three most common types of N95 FFRs used in your health care facility? If not listed, please provide the name of the manufacturer and model number.	3M™ 1860/1860S 3M™ Aura™ 1870+ 3M™ 8210/8110S 3M™ Aura™ 9210+ 3M™ VFlex™ 1805/1805S Gerson® 1730 Gerson® 2735 Kimberly-Clark™ PFR95-170 (46727)/PFR95174 (46827) Kimberly-Clark™ PFR N95 (62355)/PFR N95 (62126) Moldex® 1500 Moldex® 2200 series Moldex® 3000 series Safe Life® B130 Safe Life® B150 Other (please specify)
Below are examples of PAPRs (courtesy of OSHA). 5. Have any of your employees used a PAPR at least once in the past year, including training exercises or fit testing?	Yes No
6. Approximately how many of your employees have used a PAPR in the past year, including training exercises or fit testing?	10 or less 11-100 101-500 More than 500
7. What are the three most common types of PAPRs used in your health care facility? If not listed, please provide the name of the manufacturer and model number.	3M™AirMate™ 3M™ Breathe Easy™ 3M™ Versa Flo™ Bullard™ PA20™ Bullard™ PA30™ Bullard™ EVA™ Syntech International MAXAIR® ILC Dover Sentinel series Other (please specify)
Below is an example of an elastomeric half-mask respirator (courtesy of OSHA). 8. Have any of your employees used an EHFR at least once in the past year, including training exercises or fit testing?	Yes No
9. Approximately how many of your employees have used an EHFR in the past year, including training exercises or fit testing?	10 or less 11 to 100 101 to 500 More than 500
10. What are the three most common types of EHFRs used in your health care facility? If not listed, please provide the name of the manufacturer and model number.	3M™ 6000 series 3M™ 7500 series Honeywell Sperian® Survivair® Blue 1 Hversion Honeywell Sperian® Survivair® Blue 1 Sseries North® by Honeywell 5500 series Half-Mask North® by Honeywell 7700 series Half-Mask MSA Comfo Classic® Half-Mask MSA Advantage® series Half-Mask Other (please specify)
11. Do you have any comments, questions, or concerns about the material covered in this survey? If you would like a response, please provide your contact information.	(free response space)

Note. OSHA = Occupational Safety and Health Administration; FFR = filtering facepiece respirators; PAPR = powered air-purifying respirators; EHFR = elastomeric half-facepiece respirators.