COVID-19 Products

COVID-19 Incident Report for Patient or Visitor

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COVID-19 Incident Report for Patient/Visitor Exposure RLDatix Page 7 of 8 March 20, 2020 Revision 1 • (DD/MM/YYYY): • Time: COVID-19 Patient Details Date of exposure DD/MM/YYYY: __/__/____ • Not Known Does the patient provide history of living in the same household environment with a confirmed COVID-19 patient? • Yes • No • Unknown Does the patient have history of traveling in proximity (within 1 meter) with a confirmed COVID-19 patient in any kind of conveyance? • Yes • No • Unknown Was the patient in close proximity contact (within 1 meter) with a confirmed COVID-19 patient in the health care facility? • Yes • No • Unknown Was the patient 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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