COVID-19 Products

COVID-19 Incident Report for Staff Exposure

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COVID-19 Incident Report for Staff Exposure RLDatix Page 11 of 16 March 20, 2020 Revision 1 Employee interactions/activities performed on or near COVID-19 patient Does the employee provide history of living in the same household environment with a confirmed COVID-19 patient? • Yes • No • Unknown Does the employee have history of traveling in proximity (within 1 meter) with a confirmed COVID-19 patient in any kind of conveyance? • Yes • No • Unknown Did employee provide direct care to a confirmed COVID-19 patient? • Yes • No • Unknown Was the employee in face-to-face contact (within 1 meter) with a confirmed COVID-19 patient in the health care facility? • Yes • No • Unknown Was the employee present when any aerosol generating procedures (AGP) was performed? • Yes • No • Unknown If yes, what type of AGP procedure? ☐Tracheal intubation ☐Nebulizer treatment ☐Open airway suctioning ☐Collection of sputum ☐Tracheostomy ☐Bronchoscopy ☐Cardiopulmonary resuscitation (CPR) ☐Other, specify:

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