APPENDIX

SURVEY QUESTIONNAIRE

Part I. Respondent’s Profile. Please provide the information needed below by filling the blanks

and checking the choice that corresponds to your answer. Unless stated optional, never leave any

item unanswered.

Name: (Optional) Age: __________Gender: ______

Category as Healthcare Worker: ( ) Doctor
( ) Nurse
( ) Midwife
( ) Nursing Attendant
( ) Janitorial Services
Length of Service in the Institution: ( ) 0-3 years
( ) 3-6 years
( ) 6-9 years
( ) 9-12 years
( ) > 12 years

Part II. Knowledge. Select the best answer. Encircle the letter that corresponds to your answer.

Hand hygiene

1. The main medical purpose of hand hygiene is to:

a. cleanse the hands of pathogens (including bacteria or viruses) and chemicals
b. provide moisture to hands
c. remove visible soiling
d. remove 100% microorganisms in the hands
2. After medical hand hygiene, drying hand with:
a. Electric hand dryers are effective than paper towels
b. Paper towels are effective that electric hand dryers
c. Let alone air drying is effective than electric hand dryers
d. Allowing moisture to remain on hands is effective than paper towels
3. Hand sanitizers must contain:
a. 40% alcohol
b. 70% alcohol
c. 90% alcohol
d. 95% alcohol
4. Hand hygiene can be done:
a. With water only
b. With water and soap only
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 c. Without water also
d. With water and strong disinfectants only
5. Medical handwashing is done by:
a. Keeping hands in line with fingers and wrist
b. Keeping hands in line with wrist and forearm
c. Keeping hands below wrist and forearm
d. Keeping hands above wrist and forearm
6. Surgical handwashing is done by:
a. Keeping hands in line with fingers and wrist
b. Keeping hands in line with wrist and forearm
c. Keeping hands below wrist and forearm
d. Keeping hands above wrist and forearm
7. The most effective temperature for handwashing:
a. Hot water
b. Warm, soapy water
c. Cold, soapy water
d. Cold water
8. Hand sanitizers are most effective on:
a. Bacteria
b. Viruses
c. Prions
d. Spores
9. Hand hygiene is done
a. A minimum of 5 seconds
b. A minimum of 10 seconds
c. A minimum of 30 seconds
d. A minimum of 15 seconds
10. Hand hygiene is done on all occasions except:
a. Before patient care
b. During aseptic technique
c. After environmental contact
d. After patient care.

Double Gloving
1. The glove failure rate is ______with double gloving as with single.
a. Lesser than
b. Greater than
c. Equally high
d. Not certain
2. Perforations in single-gloves are detected:
a. just as easily as with double-gloving
b. better than with double gloving
c. least than with double gloving
d. not certainly with double gloving.
3. Wearing two pairs of gloves will:

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 a. Not affect tactile sensitivity.
b. Cause dangerous decrease in tactile sensitivity.
c. Cause increase in tactile sensitivity.
d. Have no effect on sensation
4. Glove barrier failure:
a. Is rare
b. Is common
c. Is not encountered
d. Not noticed.
5. Gloves should be changed when:
a. It is visibly soiled
b. It is perforated
c. Having contact with different patient.
d. Before a procedure
6. Double gloving should be done:
a. In special cases
b. At all times
c. Every patient contact
d. In all surgical procedures
7. Gloves worn should be:
a. Larger than the usual glove size
b. Smaller than usual glove size
c. Glove size that fits snugly into hands
d. Any glove size as long as it would provide protection.
8. Why is double gloving recommended?
a. Provides additional level of protection to hands
b. Eliminates possibility of perforation
c. Increase the risk of tears
d. Maintains intact skin
9. Needle stick injuries are ________ with double gloving technique:
a. Increased
b. Eliminated
c. Decreased
d. Unknown
10. Gloves used for double gloving are:
a. Examination gloves
b. Utility gloves
c. Orthopedic gloves
d. Surgical gloves

Protective Clothing

1. Soiled gowns should be disposed:

a. After performing all procedures
b. As soon as possible

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 c. Before doing another procedure
d. After proper handwashing
2. Who should use PPE when there will be contact with blood or other bodily fluids?
a. Healthcare workers
b. Patients
c. Visitors
d. All of the above
3. Disposable gowns are made of:
a. fabric that can withstand repeated laundering in hot water,
b. usually cotton and is fastened at the back with twill tape ties.
c. paper or thin plastic, with paper or plastic ties
d. Light skid material
4. A hospital gown is also called:
a. Johnny
b. Lucille
c. Joe
d. Amy
5. Gowns should be:
a. Short-sleeved
b. Long-sleeved with cuffs
c. Long-sleeved with elastic cuffs
d. Short-sleeved with collar
6. Gowns should be:
a. Disposable
b. Strong to withstand repeated laundering
c. Both a and b
d. Neither a and b
7. Soiled gowns:
a. Should be placed in the same container
b. Stored in a designated place
c. Sorted prior to disposal or laundering
d. Stored and disinfected prior to laundering
8. A surgical mask helps by:
a. stopping germs in your nose and mouth from spreading
b. Keeping you from breathing in some germs.
c. Keeping you from coming in contact with sudden splashes of fluids
d. All of the above
9. Protective clothing include:
a. Head cover, gown
b. Head cover, gown, face shield
c. Head cover, gown, goggles, mask
d. Head cover, gown, mask, eyewear
10. Facemask should be removed:
a. First before removing gloves and gown
b. Before removing gloves

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 c. After removing gown
d. Last after removing all soiled items

Protective Eyewear

1. Goggles should be:

a. Appropriately fitted
b. Directly-vented with a manufacturer’s anti-fog coating
c. Large to avoid irritating nose bridge
d. A and b
2. Eye protection provides a barrier to infectious materials entering the eye and is often
used:
a. Alone
b. In combination with mask
c. In combination with gown and mask
d. In combination with all PPEs.
3. Eyewear should be:
a. Physically cleaned
b. Air dryed
c. Washed with disinfectant
d. All of the above
4. Goggles are more efficient protective barrier than faceshields.
a. True
b. False
c. None of the above
d. Both a and b
5. Eye protection should be placed in ______________for subsequent cleaning and
disinfection.
a. Designated receptacle
b. Together with soiled PPEs
c. Disposed after use
d. A dry, isolated and distant corner
6. Another worker:
a. Should have his/ her own eyewear
b. May reuse other eyewear
c. May borrow from co-worker
d. May use properly stored eyewear
7. Contaminated eye protection devices should be reprocessed in an area where:
a. It is free from contact with other materials
b. other soiled equipment is handled
c. there is a designated receptacle for disposal
d. it is free from contact by worker and patients
8. Fluids that may come in contact with eyes that can be considered to transmit blood-borne
diseases include:
a. Urine

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 b. Sweat
c. Tears
d. Amniotic fluid
9. To adequately protect yourself from infection/ contamination, eyewear should always be:
a. Disposable
b. Disposed properly
c. Processed according to manufacturer’s instructions
d. All of the above
10. Eyewear should be removed:
a. After removing gown
b. Before removing gown
c. After removing gloves
d. Before removing gloves

Footwear

1. Everyday footwear are considered protective if:

a. It is branded as Crocs
b. It covers the toes
c. It keeps your feet from contact with fluid
d. Free from holes but frees your toes to reduce friction.
2. Soiled footwear should be processed with:
a. 1:20 lysol solution
b. 1:10 chlorine solution
c. 1:30 vinegar solution
d. 1:10 disinfectant
3. Footwear are only deemed appropriate if:
a. They fit the feet snugly
b. Prevent blood from passing through the skin
c. Prevent blood from passing though the material
d. They match with uniform colors.
4. Footwear include:
a. Shoes with absorbent material
b. Shoes with cotton fabric
c. Shoes that is non-absorbent
d. Shoes made of plastic
5. Shoe covers should be worn by:
a. Healthcare workers
b. Patients
c. Visitors
d. All of the above
6. Shoe covers can help create a barrier between the skin and the source of microorganism.
a. True
b. False
c. Most of the time

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 d. None of the above
7. Disposable shoe covers should be:
a. Stored in a designated receptacle
b. Disposed properly
c. Reprocessed properly
d. Burned at a designated area
8. Protective footwear should be:
a. Stored in a designated receptacle
b. Disposed properly
c. Reprocessed properly
d. Buried at a designated area
9. Shoe covers are used for:
a. Bioexclusion
b. Body surface isolation
c. Environmental surface isolation
d. Biohazard isolation
10. Shoe covers should be:
a. Changed every shift
b. Changed after performing all procedures
c. In between patient contact
d. Before disposing gloves

Part III. Attitude. This questionnaire is to describe your perception of the practice on the use of
Standard Precaution in the workplace. Please answer all the items in the answer sheet. Check the
box that responds to your answer.
Legend: 1- Never
2- Occasionally
3- Most of the Time
4- Always

Attitude 1 2 3 4
Hand hygiene
1. Performs hand hygiene prior to contact to patient.
2. Performs hand hygiene every after body fluid exposure.
3. Performs hand hygiene every after touching a patient.
4. Performs hand hygiene after touching patient
environment.
5. Performs hygiene before doing an aseptic technique.
Double Gloving
1. Use double gloving when touching blood, body fluids,
secretions, excretions, mucous membranes, and
nonintact skin.
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 2. Practice changing of gloves between tasks on the same
patient after contact with potentially infectious
material.
3. Performs double gloving when passing sharp surgical
instruments.
4. Change gloves prior to contact to another patient.
5. Performs double gloving when administering
injections.
Protective Clothing
1. Wears gown during activities that are likely to generate
splashes or sprays of blood, body fluids, secretions, or
excretions.
2. Dispose single use gowns properly.
3. Remove soiled gowns as soon as possible.
4. Wear head covers.
5. Wear facemask at all times.
Protective Eyewear/ Faceshield
1. Wears eyewear/ faceshield during activities that are
likely to generate splashes of blood and bodily fluids.
2. Wears goggles when suctioning a patient or upon
intubation.
3. Wear goggles when attending vaginal deliveries
4. Wear goggles when assisting an operation?
5. Wear goggles when doing activities that are likely to
generate excretions.
Footwear
1. Wear proper footwear when there is a possibility of
coming in contact with spillage of blood and other
body fluids.
2. Wear proper footwear when there is a possibility of
coming in contact with large quantities of infective
material?
3. Wears proper footwear when attending to patients
when you have breaks in the skin?
4. Take off soiled proper footwear wipe them down with
a 1:10 chlorine solution.
5. Wear proper footwear when visiting loved ones with
serious illness like HIV and AIDS.

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Part IV. Logistic Support. Check the box that responds to your answer.

Legend: 1- Strongly Disagree

2- Disagree
3- Agree
4- Strongly Agree

Logistic Support 1 2 3 4
Provision/ Availability of Personal Protective Equipments
1. Agents for hand hygiene are adequately provided.
2. Gloves are adequately supplied at all times.
3. Gowns are adequately provided for personnel.
4. Protective eyewear and faceshield are adequately
provided to personnel.
5. Footwear are available for every personnel.
Availability of Facilities for Early Detection, Screening and
Prevention
1. Reagents for screening Blood-borne diseases are
available at all times.
2. Reagents for proper disinfection available at all times.
3. Vaccinations against blood-borne pathogens are
provided by the hospital to its personnel.
4. Contingency fund are available to support personnel
who encounters needle stick or sharp injuries.
5. Reporting system for needle stick and sharp injuries are
facilitated.
Skill Enhancement Program
1. Trainings on the use of Standard Precaution are
adequately provided by the hospital.
2. Lectures and seminars on the use of Standard Precaution
are adequately provided by the hospital.
3. Materials are provided by the institution to supplement
knowledge on the use of Standard Precaution.
4. Regular updates on Infection control practices and the
use of Standard Precaution are provided by the hospital
5. Effective evaluation programs on the implementation of
Standard Precaution.

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Part V. Compliance. Check the box that responds to your answer.

Legend: 1- Strongly Disagree

2- Disagree
3- Agree
4- Strongly Agree

Compliance 1 2 3 4
Hand hygiene
1. I practice hand hygiene prior to contact to patient.
2. I practice hand hygiene every after body fluid
exposure.
3. I practice hand hygiene every after touching a patient.
4. I practice hand hygiene after touching patient
environment.
5. I practice hand hygiene before doing an aseptic
technique.
Double Gloving
1. I use double gloving when touching blood, body fluids,
secretions, excretions, mucous membranes, and
nonintact skin.
2. I practice changing of gloves between tasks on the
same patient after contact with potentially infectious
material.
3. I perform double gloving when passing sharp surgical
instruments.
4. I change gloves prior to contact to another patient.
5. I performs double gloving when administering
injections.
Protective Clothing
1. I wear gown during activities that are likely to generate
splashes or sprays of blood, body fluids, secretions, or
excretions.
2. I dispose single use gowns properly.
3. I remove soiled gowns as soon as possible.
4. I wear head covers.
5. I wear facemask at all times.
Protective Eyewear
1. I wear eyewear/ faceshield during activities that are
likely to generate splashes of blood and bodily fluids.
2. I wear goggles when suctioning a patient or upon
intubation.
3. I wear goggles when attending vaginal deliveries

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 4. I wear goggles when assisting an operation?
5. I wear goggles when doing activities that are likely to
generate excretions.
Footwear
1. I wear footwear when there is a possibility of coming
in contact with spillage of blood and other body
fluids.
2. I wear footwear when there is a possibility of coming
in contact with large quantities of infective material?
3. I wear footwear when attending to patients when you
have breaks in the skin?
4. I take off soiled footwear wipe them down with a 1:10
chlorine solution.
5. I wear footwear when visiting loved ones with serious
illness like HIV and AIDS.

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