HomeMy WebLinkAbout106.006 - EMS-16, Request for Notification Communicable Disease Status
Fresno City Fire Department
100 Administrative Manual
SECTION 106.006 REQUEST FOR NOTIFICATION: COMMUNICABLE
DISEASE STATUS (EMS-16)
PURPOSE
In the event of a potential exposure to communicable disease, the EMS-16 form is
used to request source patient transmissible disease status from the transported pa-
tient’s treating facility.
APPLICATION
Whenever there is a possible communicable disease exposure, the EMS-16 form is
to be used by the Designated Infection Control Officer (DICO). This form is to be filed
electronically in the Training Unit, T drive in a secured “DICO Only” folder.
OPERATIONAL POLICY
The EMS-16 form is used by the DICO only to request source patient information from
the treating facility. When this form is returned to the DICO, it will be reviewed and
filed in a locked file cabinet, as well as electronically filed in a secured “DICO Only”
folder on the Training Unit T drive.
OPERATIONAL GUIDELINE
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PROCESS
1. The DICO will FAX this form to the appropriate Infection Prevention
Department Office.
2. The DICO will call the hospital’s Infection Prevention Department Office
to verify receipt.
Effective Date: June 2013 Kevin Reynolds, Captain
Current Revision Date: 07/14/2022 Section 106.006
Next Revision (1) Date: 07/14/2024 Page 1 of 2
INFORMATION
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DEFINITIONS
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CROSS-REFERENCES
This form follows Cal OSHA Title 8 regulations and Ryan White act laws.
Effective Date: June 2013 Kevin Reynolds, Captain
Current Revision Date: 07/14/2022 Section 106.006
Next Revision (1) Date: 07/14/2024 Page 2 of 2
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EMS-16
REQUEST FOR NOTIFICATION: COMMUNICABLE DISEASE STATUS
Source Patient Information: DICO Log #
Source Patient Name: Source Patient DOB:
Location Transferred:
Children’s Hospital
Clovis Community
Kaiser
CRMC
Madera
St. Agnes VA
Date of Exposure: Time:
Location:
Fresno Fire Department Incident No:
Source Patient Hospital Encounter
Number:
Type of Exposure (Check those that
apply)
Additional Comments or Information
Blood to Blood
Mouth to Mouth
Aerosolized Respiratory
Aerosolized Droplet
Open Wound
Detailed description of exposure event:
Agency Information: The exposed individual is an employee of the Fresno Fire Department. Refer questions to
Designated Officer (559) 621-4155. Please fax results to (559) 457-1198 or (559) 457-1262.
Instructions: Designated Officer/Contact Person will FAX this form to the appropriate Infection Prevention Department Office.
Call the Infection Prevention Department Office to verify receipt.
HOSPITAL USE ONLY – INFECTION PREVENTION SECTION
COUNTY HEALTH OFFICER NOTIFIED: YES NO UNABLE TO DETERMINE
Comments, if applicable:
Infection Prevention
Office Signature: Date:
Fax Date/Time/Number: