Communicable Disease Exposure Report
INTENT: This form is used to report your exposure to any communicable disease, including possible Coronavirus exposure.

INSTRUCTIONS: Please complete the following form as completely as possible. Use department email. Upon completion, you will receive a confirmation email. Thank you.
Email address *
Enter the Date *
MM
/
DD
/
YYYY
Time
:
What was the Incident Run Number? *
Your answer
Incident Location *
Your answer
Patients Name *
Your answer
Patient Date of Birth *
MM
/
DD
/
YYYY
Crew Member Exposed *
Your answer
Rank of Crew Member Involved *
Apparatus You are On *
Ambulance Unit *
Your answer
Receiving Hospital *
Patient Symptoms *
Required
Was this patient TESTED POSITIVE for COVID-19 *
PPE Used by CCFD *
Required
Was a Mask or Non-Rebreather Placed on the Patient? *
Were CPAP, CPR, or other Aerosol Procedures performed while you were in the room? *
Comments:
Your answer
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