COVID-19 Products

COVID-19 Incident Report for Staff Exposure

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COVID-19 Incident Report for Staff Exposure RLDatix Page 4 of 16 March 20, 2020 Revision 1 Introduction RLDatix has prepared this sample staff exposure form to help our customers track COVID-19 related staff events. This form represents a compilation of common fields that we have seen on various forms available in the public domain. This form is not intended to be specific to any particular jurisdiction, and as such, customers are encouraged to view this form as a starting template and make any necessary modifications to comply to local reporting requirements. Using the form design functionality within the RLDatix software, customers can choose to build this form in their current instance of the RLDatix software, or they can take elements from this form and modify an existing form currently in place for staff/employee event tracking. Should a customer need assistance building/modifying a form, please submit a support ticket to RLDatix and our customer support teams will be happy to assist. Form Preview Employee Information Last name: Employee # First name: Age: Sex: ☐Male ☐Female ☐Prefer not to answer Address: Contact details: Was Employee N95 fit tested ☐Yes ☐No Was employee trained and fitted for Powered Air- Purifying Respirators (PAPR). ☐Yes ☐No ☐NA Was employee using appropriate fit tested mask at the time of event? ☐Yes ☐No ☐Unknown Type of health care personnel: ☐Medical Doctor ☐Physician Assistant (PA) ☐Registered Nurse ☐Registered Practical Nurse / Licensed Practical Nurse ☐Assistant Nurse, Nurse technician, Nurse Aid (or equivalent) ☐Radiology /Diagnostic Imaging Technician ☐Phlebotomist ☐Ophthalmologist ☐Physical Therapist ☐Respiratory Therapist ☐Nutritionist/Dietitian ☐Midwife ☐Pharmacist

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