FORMS
106.6 REQUEST FOR NOTIFICATION: COMMUNICABLE
DISEASE STATUS
EFFECTIVE: JUNE 2013
INFORMATION SHEET
Form Number: EMS-16
Title: REQUEST FOR NOTIFICATION:
COMMUNICABLE DISEASE STATUS
Contents: Request source patient transmissible disease status from the transported patient’s treating facility.
Frequency: As-needed basis whenever there is a possible communicable disease exposure.
Responsibility: Designated Infectious Control Officer (DICO)
Channels Through: DICO
Remarks: This form will be used only by the DICO and shall be filed electronically in the Training Unit T drive in a secured “DICO Only” folder.
Cross References: This form follows Cal OSHA title 8 regulations and Ryan White act laws
Section 106.6
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INSTRUCTION SHEET
This form shall be 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.
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.
Designated Officer/Contact Name: Captain Gregg Skaggs or Captain Kevin Reynolds
Instructions: If necessary, go with the patient to the hospital and request Emergency Department physician/nurse to run tests on the source patient. 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
Section 106.6
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Section 106.6
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