HomeMy WebLinkAbout106.070 - EMS-17, DICO Exposure Interview Report
ADMINISTRATIVE MANUAL
FORMS
106.070 DICO EXPOSURE INTERVIEW REPORT
(EMS-17)
EFFECTIVE: JUNE 2013
Current Revision Date: 12/27/18 Next Revision Date: 12/27/19
Author’s Name/Rank: Jonathan Lopez-Galvan, Engineer Review Level: 1
PURPOSE
The DICO Exposure Interview Report form (EMS-17) is used by the Designated
Infectious Control Officer (DICO) to conduct an interview of a member who is
reporting a suspected communicable disease exposure.
APPLICATION
The EMS-17 form is used to guide the DICO through an interview to gather all the
appropriate information on all suspected exposures. If additional persons were
involved, additional copies of this form for each person involved are to be attached.
Once the form is completed by the DICO, it is to be reviewed and filed in a locked
file cabinet, as well as electronically filed in a secured “DICO Only” folder on the
Training Division T drive.
OPERATIONAL POLICY
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OPERATIONAL GUIDELINE
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PROCESS
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INFORMATION
This form follows Cal OSHA Title 8 regulations.
Section 106.070
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DEFINITIONS
Exposure Incident
CROSS REFERENCES
Administrative Manual
Section 203.10, Infection Control
Section 106.070
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EMS-17
FRESNO FIRE DEPARTMENT
DICO EXPOSURE INTERVIEW REPORT
DICO LOG
In case of employee exposure to infectious disease, complete this form while interviewing
exposed employee during post-exposure evaluation. If other persons were involved, attach
additional copies of this form for each person involved.
Date of Report: / / Time of Report:
FFD Inc#: EMS#:
Employee Information
Employee Name (Last, First, M.I.):
Sex: Male Female Date of Birth: / / Employee ID#:
Address (Home):
Home Phone: Cell Phone:
Has the employee been immunized against Hepatitis B Virus? Yes No
Duties related to exposure:
Address where exposure incident occurred:
Names of crew members present:
List any other agencies present:
Personal protective equipment in use at time of exposure (Check all that apply):
Gloves Eye Protection Gown Mask
Other:
Type of Exposure
Source of Exposure: (Check all that apply)
Body fluid with visible blood Seminal Fluid Air Borne Cerebrospinal
Internal body fluids Synovial Pleural Amniotic
Vaginal secretions Pericardial Peritoneal Blood
Saliva Vomitus Feces Urine Tears
Sputum Sweat
Other:
Needle stick/sharps accident: Yes No
Contact with mucous membranes? (check all that apply) Eyes Mouth Nose
Contact with skin – Any non-intact skin involved? Yes No
If Yes (Check all that apply)
broken chapped abraded dermatitis prolonged contact
extensive contact
Severity of Exposure
How much fluid?
How severe was the injury?
Estimated time interval from exposure until medical evaluation:
Section 106.070
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What part(s) of your body became exposed? Be specific:
Describe Activity Leading to Exposure: (Check all that apply)
Recapping needle Discarding needle Handling IV line
Handling disposal box Handling waste products Cleaning blood spill
Controlling bleeding Performing invasive procedure Other
Precisely describe situation:
Describe immediate interventions:
Was the area washed/flushed? Describe:
Did injury bleed freely? Yes No
Was antiseptic applied? Yes No
Describe nature and scope of personal injury, if any.
Was medical treatment obtained? Yes No
Source individual, if known
Name Address Telephone
Facility source person was transported to:
Transported by:
Yes No
Infectious status of source confirmed:
Is a blood sample from the source available?
Is the source individual’s HBV antigen/antibody status known?
Is the source individual’s HIV antibody status known?
Exposure Response
No exposure/No follow up True exposure Insufficient information
Follow up to be done at:
Recommendation:
DICO Signature Date
Section 106.070
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