COVID-19 Products

COVID-19 Incident Report for Staff Exposure

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COVID-19 Incident Report for Staff Exposure RLDatix Page 9 of 16 March 20, 2020 Revision 1 Employee Information Last Name: First Name: Employee #: 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 • N/A Was employee using appropriate fit tested mask at the time of the 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 ☐Pharmacy Technician ☐Laboratory Personnel ☐Admission/Reception Clerk ☐Engineering / Facility Services ☐Patient Transporter ☐Food Service Staff ☐Cleaner

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