HomeMy WebLinkAboutEMS-16 - Request for Notification Communicable Disease Status
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 the 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: