<p> ADMINISTRATIVE MANUAL</p><p>FORMS</p><p>106.5 COMMUNICABLE DISEASE EXPOSURE REPORT</p><p>EFFECTIVE: JUNE 2008</p><p>INFORMATION SHEET</p><p>Form Number: EMS-15</p><p>Title: COMMUNICABLE DISEASE EXPOSURE REPORT</p><p>Contents: Communicable disease exposure reporting procedure for members seeking immediate medical treatment following exposure. This policy includes testing and treatment plans for the physician’s reference.</p><p>Frequency: All communicable disease exposures.</p><p>Responsibility: Exposed members, supervisors, or the Designated Infectious Control Officer (DICO)</p><p>Channels Through: DICO</p><p>Remarks: This form will be given to the treating physician and faxed or given directly to the DICO for follow up on an exposure case.</p><p>Cross References: This policy follows all guidelines set from Cal OSHA Title 8.</p><p>Administrative Manual Section 203.10, Infection Control</p><p>Revised 6/17/13 Section 106.5 Page 1 of 5 INSTRUCTION SHEET</p><p>This policy shall be placed on all Department apparatus to instruct members on required procedures to follow on a communicable disease exposure. The first two pages have basic instructions and checklists to guide the member through the reporting process. </p><p>The form on page 5 shall be completed with the exposed member’s information. </p><p>Once completed, the form shall be given to the treating physician upon arrival at the treating facility. </p><p>This form includes instructions on needed testing and an area for the physician to document treatment, follow-up plan, and instructions to return processed form to the DICO for follow-up. </p><p>When this form is returned to the DICO, it will be reviewed, and a hard copy will be kept in a locked file cabinet, as well as electronically filed in a secured “DICO Only” folder on the Training Unit T drive. </p><p>Revised 6/17/13 Section 106.5 Page 2 of 5 COMMUNICABLE DISEASE EXPOSURE REPORTING PROCEDURE</p><p>If during the course of performing one’s duties, a member is exposed or suspects he/she has been exposed to another person’s blood and/or body fluids or has been stuck by an exposed needle, the exposure incident(s) shall be reported to the following:</p><p> appropriate supervisor,  physician or medical care provider (if medical attention is required), and  DICO</p><p>An exposure incident is defined as specific eye, mouth, mucous membrane, non- intact skin, or parenteral contact with blood, bodily fluids, or other potentially infectious materials, which results from the performance of a member’s duties. Parenteral means piercing mucous membranes or the skin barrier through such events as needle sticks, human bites, cuts, and abrasions.</p><p>Checklist: Members shall use the following guide during an exposure or suspected exposure.</p><p> Report the exposure or suspected exposure incident to supervisor. Docu- ment how the exposure occurred, the routes of exposure, the source individual and/or source material, and the situation surrounding the exposure.</p><p> Immediately report the exposure to the DICO.  Phone Number (559) 621-4155</p><p> Complete Form EMS-15, Communicable Disease Exposure Report  Section I: To be completed by the employee.  Section II: To be completed by the treating physician (if medical at- tention is sought).  Bottom Section (Exposure Response): To be completed by the DICO.</p><p> Determine if the exposed member requires medical attention. If so, medical care should be sought immediately.  Medical treatment may be obtained at one of the approved medical clinics or the hospital emergency room (when appropriate) and is pro- vided through the City Worker’s Compensation Program.  Treating physician completes Section II of Form EMS-15, Communi- cable Disease Exposure Report</p><p>Revised 6/17/13 Section 106.5 Page 3 of 5  Exposed member may decline medical attention; however, the appro- priate exposure incident report must be completed with a notation the member declined medical treatment.</p><p> Obtain consent and make arrangements to have the source individual test- ed to determine infectivity.  If the source individual is already known to be infected, new testing may not be needed.  Exposed member should be provided with source individual’s test re- sults.  If source individual refuses consent, the exposed member may be able to obtain consent through a court order.</p><p> Fax the completed Form EMS-15, Communicable Disease Exposure Report within 24 hours to the DICO at (559) 457-1198 or (559) 457-1262.</p><p> If medical attention is received, report the exposure as a work-related ill- ness within 24 hours using the City Worker’s Compensation forms and guidelines. Please include the completed Form EMS-15, Communicable Dis- ease Exposure Report, with the completed Worker’s Compensation forms when routing to the DICO.</p><p>Revised 6/17/13 Section 106.5 Page 4 of 5 EMS-15 CONFIDENTIAL</p><p>Communicable Disease Exposure Report</p><p>Reporting Procedure</p><p>Any member who believes he/she has been exposed to blood, body fluids, or a disease shall: 1. Report the exposure to his/her immediate supervisor 2. Follow the Department reporting procedures, 3. Complete Section I (All that apply to exposed member), 4. IMMEDIATELY report exposure to the DICO at (559) 621-4155 5. If exposed member requires medical attention, treating physician completes Section II 6. Fax report to (559) 457-1198 or (559) 457-1262.</p><p>SECTION I (Complete all in SECTION I that applies to exposed member) Person Exposed Date of Time of Name exposure exposure Work Phone Cell Phone Home Phone Employer Dispatch PCR # Address/Location of exposure Other agencies present: Patient/Suspect Information Name Male Female Age Date of birth Stat Phon Address Apt # City e e Patient destination: Type of Exposure Blood Body Fluid Respiratory Illness Other Briefly Describe Incident Signature of Designated Officer / Designee:</p><p>SECTION II Treatment & Testing Guidelines (This section completed by treating physician) 1. Rapid HIV and HCV (within 2 Hours) 2. Syphilis 3. Hepatitis B (HBIG) if no prior infection or vaccine 4. Baseline Hepatitis C 5. Tetanus, if last shot was more than ten (10) years ago 6. Testing for HIV – If no HIV testing available at your facility, you can refer the patient to Firm Associates to begin the testing process IMMEDIATELY report exposure to the DICO at (559) 621-4155; Fax (559) 457-1198 or (559) 457-1262 Services Rendered by Treating Physician:</p><p>Follow Up Plan: Treating Physician’s Signature</p><p>No Exposure/No Follow Unable to contact exposed to verify if exposure Exposure Response from DICO: Up occurred True Exposure – Follow up to be done at: Recommendations DICO Signature</p><p>Revised 6/17/13 Section 106.5 Page 5 of 5</p>