THREAT-PREPAREDNESS & BIOTERRORISM RESPONSE LABORATORY OFFICE OF LABORATORY SERVICES BUREAU OF PUBLIC HEALTH 167 Eleventh Avenue, South Charleston, West Virginia 25303 http://www.wvdhhr.org/labservices LABORATORY RESPONSE NETWORK (LRN) SURVEY QUESTIONNAIRE (1). Do you process any microbiological specimens in house? If no, skip to question (9). □ Yes □ No (2). If yes, what types of microbiological testing is performed in the laboratory and what types of specimens do you accept for each type of testing? G G G G
Bacteriology ________________________________________________________________________ ________________________________________________________________________ Parasitology ________________________________________________________________________ ________________________________________________________________________ Virology ________________________________________________________________________ ________________________________________________________________________ Mycology ________________________________________________________________________ ________________________________________________________________________
(3). Do you process all microbiological specimens to a final culture, identification and sensitivity result in house? □ Yes □ No (4). Do you process any microbiological specimens to a final culture, identification and sensitivity result in house? □ Yes □ No (5). If yes, which type of specimens do you process to a final culture, identification and sensitivity? (If applicable.) G G G G
Bacteriology Parasitology Virology Mycology
(6). What other type of testing is performed in the laboratory and what types of specimens do you accept for each type of testing? G G G G
Chemical
________________________________________________________________________ ________________________________________________________________________ Serological ________________________________________________________________________ ________________________________________________________________________ Environmental ______________________________________________________________________ ________________________________________________________________________ Foreign Objects ______________________________________________________________________ ________________________________________________________________________ JRW 11/07/03
THREAT-PREPAREDNESS & BIOTERRORISM RESPONSE LABORATORY OFFICE OF LABORATORY SERVICES BUREAU OF PUBLIC HEALTH 167 Eleventh Avenue, South Charleston, West Virginia 25303 http://www.wvdhhr.org/labservices LABORATORY RESPONSE NETWORK (LRN) SURVEY QUESTIONNAIRE
(7). Does your laboratory have guidelines or protocols in place to handle clinical specimens used in a Bioterrorism incident? (Please see attached AList of Category A, B, and C agents) □ Yes □ No If yes, do they include: Safe Collection Safe Processing Labeling Packaging/Shipping Safe Transport Storage Disposal/Decontamination
Yes
No
9 9 9 9 9 9 9
9 9 9 9 9 9 9
(8). Is your laboratory able to provide standard microbiological methods to investigate potential Bioterrorism incidents? □ Yes □ No If your answer is yes, do they include? Gram stain morphology Culture identification Biochemical test (please indicate what system) Susceptibility test
Yes 9 9 9 9
No 9 9 9 9
(9). Does your laboratory send all microbial cultures to a reference laboratory for work-up? If yes, you may skip question (10). □ Yes □ No Does your laboratory send all microbial cultures to an out-of-state reference laboratory? □ Yes □ No Does your laboratory send all microbial cultures to an in-state reference laboratory? □ Yes □ No Does any reference laboratory used send microbial cultures for further identification at another reference laboratory? □ Yes □ No
JRW 11/07/03
THREAT-PREPAREDNESS & BIOTERRORISM RESPONSE LABORATORY OFFICE OF LABORATORY SERVICES BUREAU OF PUBLIC HEALTH 167 Eleventh Avenue, South Charleston, West Virginia 25303 http://www.wvdhhr.org/labservices LABORATORY RESPONSE NETWORK (LRN) SURVEY QUESTIONNAIRE
If Yes, to any of these, please identify the laboratory(s): __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________
(10). Does your laboratory send any microbial cultures to a reference laboratory for work-up? □ Yes □ No Does your laboratory send any microbial cultures to an out-of-state reference laboratory? □ Yes □ No Does your laboratory send any microbial cultures to an in-state reference laboratory? □ Yes □ No Does any reference laboratory used send microbial cultures for further identification at another reference laboratory? □ Yes □ No If Yes, to any of these, please identify the types of specimens and the laboratory(s): __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________
(11). Are you a reference laboratory yourself? □ Yes □ No If yes, for whom and are you paid for your services? __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ (12). Does your laboratory/facility/agency have guidelines or protocols in place to address referral of Asuspect@ laboratory results to the State Laboratories Division BT Lab (OLS)? □ Yes □ No (13). Do you know which institutional or local health authorities that you would need to notify in case of a biological emergency? □ Yes □ No JRW 11/07/03
THREAT-PREPAREDNESS & BIOTERRORISM RESPONSE LABORATORY OFFICE OF LABORATORY SERVICES BUREAU OF PUBLIC HEALTH 167 Eleventh Avenue, South Charleston, West Virginia 25303 http://www.wvdhhr.org/labservices LABORATORY RESPONSE NETWORK (LRN) SURVEY QUESTIONNAIRE
(14). Who would you notify in a biological emergency? G G G G G G G G G G G G G
Local Health Department State Health Department Infection Control/ ID physician Lab Administrator/Director/Pathologist Hospital Administrator Internal Safety Officer CDC Affiliated Institution Patient's physician FBI State Police HazMat Don't know
(15). Is your laboratory/facility/agency familiar with the Laboratory Response Network and its role in public health preparedness in response to Bioterrorism? □ Yes □ No (16). Is your laboratory interested in participating in the Laboratory Response Network? □ Yes □ No If your answer is yes, please provide the following: Name of Contact Person ____________________________________________________________________ Address ____________________________________________________________________ Telephone No. ____________________________________________________________________ E-mail address ____________________________________________________________________ Please Note: If you do not process any microbiological specimens in house, please skip questions (17)-(27). (17). Do you process microbiological specimens from all anatomical sites? □ Yes □ No If yes, approximately how many a month?
______________________________________________________
If no, where are specimens referred? __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ JRW 11/07/03
THREAT-PREPAREDNESS & BIOTERRORISM RESPONSE LABORATORY OFFICE OF LABORATORY SERVICES BUREAU OF PUBLIC HEALTH 167 Eleventh Avenue, South Charleston, West Virginia 25303 http://www.wvdhhr.org/labservices LABORATORY RESPONSE NETWORK (LRN) SURVEY QUESTIONNAIRE
(18). Which of these culture media do you use routinely, or have available? G G G G G G G G G G G G
5% Sheep blood agar Chocolate agar MacConkey agar Trypticase soy broth Brain heart infusion broth Thioglycollate broth Motility test medium Urea agar Phenylethyl alcohol agar (PEA) Cefoperazone-vancomycin-amphotericin B (CVA) Martin Lewis Cysteine heart agar
(19). Does your laboratory perform blood cultures using commercially available systems? □ Yes □ No (20). Which system(s) does your laboratory use for bacterial identification? (You may check more than one response.) G G G G G G G G G G
MicroscanTM conventional system MicroScanTM WalkAway System VitekTM System BO Enterotube 11TM BBL1M Crystal ID_ API 20E Biolog Sensititre_ PASCO_ Other (please specify)
(21). Which of these rapid presumptive tests does your laboratory perform routinely? (You may check more than one response.) G G G G
Gram Stain test Motility test Spot oxidase test India ink prep
JRW 11/07/03
THREAT-PREPAREDNESS & BIOTERRORISM RESPONSE LABORATORY OFFICE OF LABORATORY SERVICES BUREAU OF PUBLIC HEALTH 167 Eleventh Avenue, South Charleston, West Virginia 25303 http://www.wvdhhr.org/labservices LABORATORY RESPONSE NETWORK (LRN) SURVEY QUESTIONNAIRE
(22). Which anti-microbial susceptibility testing is performed by your laboratory? G G G G
MicroScan SystemTM Macro-broth dilution Disc diffusion Other (specify)
(23). Of the total number of qualified laboratory staff, how many have more than 8 hours training to rule out the following biological agents using CDC-recommended Sentinel Level (Formerly Level A) Protocols and/or identify E. coli O157:H7? G G G G G
Bacillus anthracis ______________ Brucella spp. ______________ Yersinia pestis ______________ Francisella tularensis ______________ E. coli O157:H7 ______________
(24). Which protocols are/would be used in your laboratory to presumptively identify the following organisms: (Please check the appropriate box.) For B. anthracis G Gram stain morphology G Culture morphology G Motility test (specify if wet mount or tube motility) G Hemolysis on blood agar G India ink staining for capsule (blood and CSF) G Other (please specify): ____________________________________________________________________________________
For Brucella spp. G Gram stain morphology G Culture morphology on Sheep Blood Agar G Biochemical tests such as: (Circle) Urea hydrolysis Oxidase G Other (please specify): ____________________________________________________________________________________
JRW 11/07/03
THREAT-PREPAREDNESS & BIOTERRORISM RESPONSE LABORATORY OFFICE OF LABORATORY SERVICES BUREAU OF PUBLIC HEALTH 167 Eleventh Avenue, South Charleston, West Virginia 25303 http://www.wvdhhr.org/labservices LABORATORY RESPONSE NETWORK (LRN) SURVEY QUESTIONNAIRE
For F. tularensis G Gram stain morphology G Culture morphology on: (Circle) Broth media Agar media G Other (please specify): ____________________________________________________________________________________
For Y. pestis G Gram Stain Morphology G Bipolar staining G Growth characteristics in: (Circle) Broth media Sheep blood agar G Other (please specify): ____________________________________________________________________________________
(25). Does your laboratory perform cell culture for viral isolation? □ Yes □ No If yes, please list cell line(s) used. __________________________________________________________________________________________ __________________________________________________________________________________________
(26). Does your laboratory bank (store or save) any unusual or particularly virulent isolates? □ Yes □ No
(27). Does the laboratory have the capabilities to accommodate surge capacity for biologic agents through formal agreements by performing: (Check all that apply) G G G
Perform molecular typing of organisms for epidemiology (e.g. DNA fingerprinting)? Test for unusual pathogens under Biosafety Level 3 conditions? Use molecular methods (e.g. PCR) for direct detection of unusual pathogens?
JRW 11/07/03
THREAT-PREPAREDNESS & BIOTERRORISM RESPONSE LABORATORY OFFICE OF LABORATORY SERVICES BUREAU OF PUBLIC HEALTH 167 Eleventh Avenue, South Charleston, West Virginia 25303 http://www.wvdhhr.org/labservices LABORATORY RESPONSE NETWORK (LRN) SURVEY QUESTIONNAIRE (28). What is the total number of microbiologist/medical technologists in your laboratories who are qualified to perform microbiological investigation? (Please check only one response.) G G G G
Zero to five Six to ten Eleven to fifteen More than fifteen
(29). Please list the personnel types for your laboratory. __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________
(30). Please list an Infection Control Practitioner for your laboratory and their contact information. __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________
(31). Are you capable of providing volunteer surge capacity for screening (Please see attached explanation of ASurge Capacity@)? □ Yes □ No If yes, identify potential volunteers who are capable/willing to help. (Possible agreements with personnel/students for volunteer help.) __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ (32). What is the designated Biosafety Level (BSL) of your laboratory? Note that the description of each BSL is based on the Centers for Disease Control and Prevention/National Institute of Health publication - 4th edition Biosafety in Microbiological and Biomedical Laboratories. Please check only one response. G G G G
Biosafety Level 1 Biosafety Level 2 Biosafety Level 3 Do not have copy
JRW 11/07/03
THREAT-PREPAREDNESS & BIOTERRORISM RESPONSE LABORATORY OFFICE OF LABORATORY SERVICES BUREAU OF PUBLIC HEALTH 167 Eleventh Avenue, South Charleston, West Virginia 25303 http://www.wvdhhr.org/labservices LABORATORY RESPONSE NETWORK (LRN) SURVEY QUESTIONNAIRE (33). Have you implemented engineering controls to minimize or prevent production of infectious aerosols? □ Yes □ No (34). Does your Microbiology laboratory use the following in accordance with your Biosafety Level? Class II Biosafety Cabinet □ Yes □ No Standard Microbiological Safety Practices □ Yes □ No (35). Is any member of the laboratory staff appropriately fitted for and trained to use personal protective equipment? □ Yes □ No If yes, how many?
_________________________________________________________________________
Are you planning to train more? □ Yes □ No (36). What is the level of security of your facility? G G G G
High Moderate Low None
(37). Is lab security consistent, at minimum, with guidelines set forth in Appendix F of the CDC-NIH publication, 4th edition Biosafety in Microbiological and Biomedical Laboratories (BMBL)? □ Yes □ No □ Do not have copy (38). Does the laboratory have lock-able refrigerators, freezers, and incubators? □ Yes □ No Please list: ________________________________________________________________________________ (39). Does laboratory personnel recruitment, retention, and hiring policies comply with the PATRIOT ACT of 2001 (18 USC section 175b as added by section 817:P.L. 107-56)? □ Yes □ No (40). Do you have the most recent copies of the Federal Guidelines and Regulations for packaging and shipping infectious material? □ Yes □ No If No, would you like a copy? □ Yes □ No JRW 11/07/03
THREAT-PREPAREDNESS & BIOTERRORISM RESPONSE LABORATORY OFFICE OF LABORATORY SERVICES BUREAU OF PUBLIC HEALTH 167 Eleventh Avenue, South Charleston, West Virginia 25303 http://www.wvdhhr.org/labservices LABORATORY RESPONSE NETWORK (LRN) SURVEY QUESTIONNAIRE (41). Is the individual(s) responsible for shipping in your laboratory trained or under the direct supervision of a person trained to package and ship infectious substances according to federal regulations ? □ Yes □ No (42). Do you use any of the following courier systems for shipment of clinical specimens? Please check all that apply: G G G G G G G
Quest Physician's Lab LabCorp UML SVI Regional Pathology Services Other (specify):
(43). Does the lab=s specimen/sample transportation system: G G G G G G G
Consistently meet lab expectations for proper specimen/sample handling? Consistently meet lab expectations for timeliness? Comply with current packaging and shipping regulations on infectious substances and dangerous goods? Accommodate electronic tracking of the specimen/sample in real time (similar to tracking done by package delivery services)? Accommodate transporting chemical samples? Accommodate transporting radiological samples? The lab does not have a specimen/sampling transportation system.
(44). Is your laboratory familiar with the list of agents which must be reported by your laboratory to public health? □ Yes □ No If no, would you like a copy of the list? □ Yes □ No If yes, what mechanism do you use to report these agents? G Phone only G Fax only G Mail only G Combinations of phone, mail, and fax G Other G Combination of phone, fax, mail, and other
JRW 11/07/03
THREAT-PREPAREDNESS & BIOTERRORISM RESPONSE LABORATORY OFFICE OF LABORATORY SERVICES BUREAU OF PUBLIC HEALTH 167 Eleventh Avenue, South Charleston, West Virginia 25303 http://www.wvdhhr.org/labservices LABORATORY RESPONSE NETWORK (LRN) SURVEY QUESTIONNAIRE (45). Do you encounter any problems reporting cases of reportable diseases to the county or state? □ Yes □ No (46). Do you have electronic reporting procedures for test results? □ Yes □ No (47). What are your procedures for reporting test results? Who do you report test results to? __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________
(48). With what other systems is your reporting system compatible? __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________
(49). What is/are your Laboratory Information Management System(s)? (Cerner, Sunquest, etc.) Please list each one along with in which section of the laboratory the system is used. __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________
(50). What are your Information Technology (IT) capabilities? (Software to support programs and capabilities?) __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________
(51). Do you have the ability to do web-based electronic reporting? □ Yes □ No
JRW 11/07/03
THREAT-PREPAREDNESS & BIOTERRORISM RESPONSE LABORATORY OFFICE OF LABORATORY SERVICES BUREAU OF PUBLIC HEALTH 167 Eleventh Avenue, South Charleston, West Virginia 25303 http://www.wvdhhr.org/labservices LABORATORY RESPONSE NETWORK (LRN) SURVEY QUESTIONNAIRE (52). Please indicate by putting a check in the appropriate box how often email is checked routinely by these individuals in your facility. Director of Laboratory G Several time a day G At least daily G Several times a week G At least weekly G No email capability Microbiology Supervisor G Several time a day G At least daily G Several times a week G At least weekly G No email capability (53). Please indicate by putting a check in the appropriate boxes how many of the technical level microbiology staff in your facility are able to access the Internet for work-related e-mail and training programs. G G G
All Most A Few
What number have access at work? ___________________________________________________________ What number have access at home? ___________________________________________________________ (54). Approximately what percent of microbiology staff in your facility are able to access a computer with CDRom capability for educational purposes? At home: % At work: % (55). Approximately what percent of microbiology staff in your facility are able to access a videotape player (VCR) for educational purposes? At work: % At home: % (56). What topics would you prefer to be included in Sentinel Level Lab training provided by the state health lab? G G G G G
The Sentinel Level Lab (Formerly Level A) protocols. Safe specimen handling. Packaging and shipping. Appropriate referral to higher level reference labs. Chain of custody for criminal evidence. JRW 11/07/03
THREAT-PREPAREDNESS & BIOTERRORISM RESPONSE LABORATORY OFFICE OF LABORATORY SERVICES BUREAU OF PUBLIC HEALTH 167 Eleventh Avenue, South Charleston, West Virginia 25303 http://www.wvdhhr.org/labservices LABORATORY RESPONSE NETWORK (LRN) SURVEY QUESTIONNAIRE (57). In what types of bioterrorism laboratory training would your laboratory staff be most likely to participate? G G G
Correspondence course Teleconference course On-site, one-on-one training in your laboratory
(58). Would your facility be interested in participating in an email list serve that provides current information on Bioterrorism Preparedness and Response activities at the state and federal level? □ Yes □ No (59). Which means of relationship building between your laboratory and the State Public Health Laboratory do you prefer? (Check all that apply) G G G G G
Communication with Sentinel Level (Formerly Level A) Labs through ListServes, newsletters, broadcast fax, restricted access areas of a Website, etc. Participation in local/regional emergency preparedness planning meetings with local agencies and Sentinel Level (Formerly Level A) Lab partners to facilitate defining roles and responsibilities for Sentinel Level Labs that participate in local emergency response. Participation, along side local agencies, in conducting site visits to Sentinel Level (Formerly Level A) Labs. Participation, along side local agencies, in conducting joint training exercises for emergency preparedness with Sentinel Level (Formerly Level A) Labs. Other: _____________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________
Survey was completed by: Name:
___________________________________________________________________________
Title:
___________________________________________________________________________
Institution:___________________________________________________________________________ ___________________________________________________________________________ Date:
___________________________________________________________________________ JRW 11/07/03
