COVID-19 Products

COVID-19 Form design for Job Aid

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COVID- 19 RL6 Form Design RLDatix Page 5 of 9 March 24, 2020 Step 3: Create New Fields: The COVID-19 form contains existing and new fields. See the COVID-19 Incident Report taxonomy for further details. 1. Navigate to Admin Center Fields 2. Select Module – Risk 3. Click Add New Fields: Persons Affected (Patient Demographics/Employee Information) section - • Was patient previously in another healthcare facility? o If yes, name of facility • Type of facility • Other Facility • Primary reason for visit/hospitalization • Care Team notified of potential exposure • Was Employee N95 fit tested • Was employee trained and fitted for Powered Air-Purifying Respirators (PAPR) • Was employee using appropriate fit tested mask at the time of event? • Type of health care personnel • Health care facility unit type where employee works? COVID-19 Details section – • Does the patient provide history of living in the same household environment with a confirmed COVID-19 patient? • Does the patient have history of traveling in proximity (within 1 meter) with a confirmed COVID- 19 patient in any kind of conveyance? • Was the patient in close proximity contact (within 1 meter) with a confirmed COVID-19 patient in the health care facility? • Was the patient present when any aerosol generating procedures (AGP) was performed? • If yes, what type of AGP procedure? • Did the patient have direct contact with the environment where the confirmed COVID-19 patient was cared for? E.g. bed, linen, medical equipment, bathroom, personal effects etc. • During the period of interaction • with a COVID-19 infected patient, did the patient have any episode of exposure with biological fluid/respiratory secretions? o If yes, which type of exposure? • Exposure Event Description • Describe Illness /Injury/ Effects This Exposure Event • Date of Exposure (DD/MM/YYYY) • Where multiple COVID-19 patients in health care facility at time of exposure incident? Employee Interactions & Activities section – • Does the employee provide history of living in the same household environment with a confirmed COVID-19 patient? • Does the employee have history of traveling in proximity (within 1 meter) with a confirmed COVID-19 patient in any kind of conveyance? • Did employee provide direct care to a confirmed COVID-19 patient? • Was the employee in face-to-face contact (within 1 meter) with a confirmed COVID-19 patient in the health care facility? • Was the employee present when any aerosol generating procedures (AGP) was performed?

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