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EMS-17
FRESNO FIRE DEPARTMENT
DICO EXPOSURE INTERVIEW REPORT
In case of employee exposure to infectious disease, complete this form while interviewing exposed employee during
post-exposure evaluation. If other people are 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#:
Home Address:
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:
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 the 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