HomeMy WebLinkAboutEMS-15 - Communicable Disease Exposure Report EMS-15
CONFIDENTIAL
Communicable Disease Exposure Report
Reporting Procedure
Any member who believes he/she has been exposed to blood, body fluids, or a disease shall:
1. Report the exposure to his/her immediate supervisor
2. Follow the Department reporting procedures,
3. Complete Section I (All that apply to exposed member),
4. IMMEDIATELY report exposure to the DICO at (559) 621-4155
5. If exposed member requires medical attention, treating physician completes Section II
6. Fax report to (559) 457-1198 or (559) 457-1262.
SECTION I
(Complete all in SECTION I that applies to the exposed member)
Person Exposed:
Name: Date of exposure: Time of exposure:
Work Phone: Cell Phone: Home Phone:
Employer: Dispatch: PCR #:
Address/Location of exposure: Other agencies present:
Patient/Suspect Information:
Name: Male Female Age: Date of birth:
Address: Apt #: City: State: Phone:
Patient destination:
Type of Exposure: Blood Body Fluid Respiratory Illness Other
Briefly Describe Incident:
Signature of Designated Officer / Designee:
SECTION II
Treatment & Testing Guidelines (This section completed by treating physician)
1. Rapid HIV and HCV (within 2 Hours)
2. Syphilis
3. Hepatitis B (HBIG) if no prior infection or vaccine
4. Baseline Hepatitis C
5. Tetanus, if last shot was more than ten (10) years ago
6. Testing for HIV – If no HIV testing available at your facility, you can refer the patient to Firm Associates to begin
the testing process
IMMEDIATELY report exposure to the DICO at (559) 621-4155; Fax (559) 457-1198 or (559) 457-1262
Services Rendered by Treating Physician:
Follow Up Plan:
Treating Physician’s Signature:
Exposure Response from DICO: No Exposure/No
Follow Up
Unable to contact exposed to verify if exposure
occurred
True Exposure – Follow up to be done at:
Recommendations:
DICO Signature: