EMS Policy Manual - Contra Costa Health Services

03.07.2013 Views
Name: Employer: Employer address: CONTRA COSTA HEALTH SERVICES-PUBLIC HEALTH NOTIFICATION OF POSSIBLE COMMUNICABLE DISEASE EXPOSURE (Complete all information below – PLEASE PRINT) PERSON POTENTIALLY EXPOSED Work Phone ( ) Home Phone ( ) □ Completed hepatitis B vaccination series: □ Partial hepatitis B series: □ No hepatitis B vaccinations SOURCE PERSON FOR POTENTIAL EXPOSURE: Name: Address: Location of Incident: Person transported to: Home phone: ( ) INCIDENT REPORT: Date of Incident: Time of Incident: Ambulance # Incident # TYPE OF EXPOSURE: □ Mouth to Mouth resuscitation – without protective device □ Needle stick injury - with a used/non sterile needle □ Blood or secretions splashed into → □ Eyes □ Mouth □ Wound □ Meningitis □ Close exposure to a person with TB → □ Known TB □ Suspected TB □ Other risk exposure → Please describe ________________________________________________________________________ ______________________________________________________________________________________________________________ Notify Public Health (925) 313-6740 during work hours M-F 8a-5p and Fax a copy of this form to (925) 313-6465. After hours and holidays leave a voice mail message at this same number. Public Heath will follow-up with the designated officer and/or employee during normal work hours. For urgent consults phone (925) 313-6740 to connect with the on-call Health Officer. Precautions/equipment used during this exposure: □ Gloves □ Gown □ Face shield □ Eye protection □ N95 mask □ Other: _____________________________________________________ How soon after the potential exposure were you able to cleanse the exposure site? ________________________________________ Other information regarding exposure: ____________________________________________________________________________ Occupational Health Provider: Address: Name of person completing this form: PRINT Phone PUBLIC HEALTH FOLLOW UP: □ No reportable communicable disease identified in source person □ Recommendations given to: □ Employee Date: □ Employer Date: Actions taken by Public Health: □ EMS-7 mailed to: _______________________________________ By: __________________________ Date:__________________ □ Other actions: ______________________________________________________________________________________________ Public Health follow up by: Name: Phone: ( ) ▲ □ Original to Public Health ▲ □ Copy to health facility receiving patient ▲ □ Copy to employee ▲ □ Copy to Infection Control Officer EMS – 6 (11/12)

Contra Costa Emergency Medical Services ABUSE/ASSAULT REPORTING POLICY #: 23 PAGE: 1 of 2 EFFECTIVE: 1/13 REVIEWED: 12/12 PURPOSE To describe reporting requirements for prehospital personnel when child or elder abuse, sexual assault, or domestic violence is observed or is reasonably suspected. II. CHILD ABUSE, ELDER/DEPENDENT ADULT ABUSE, AND DOMESTIC VIOLENCE EMS personnel faced with a situation where s/he has reason to suspect child abuse, elder/dependent adult abuse (physical/sexual/financial) or neglect, or domestic violence shall: A. Notify the appropriate law enforcement agency immediately if the scene is unsafe or it is suspected that a crime has been committed. B. Make reasonable efforts to transport the patient to a receiving hospital for evaluation, and provide the receiving hospital staff of abuse/neglect suspicions. C. Document observations and findings on the patient care report. D. Contact the appropriate reporting agency by telephoning immediately or as soon as reasonably possible to provide a verbal report. E. File a written report with the appropriate reporting agency within two (2) working days. III. REPORTING A. To Report Child Abuse: Complete a Suspected Child Abuse Report Form (SS8572) (available online at http://oag.ca.gov/sites/all/files/pdfs/childabuse/ss_8572.pdf?) Call Children & Family Services Screening Unit: Within 2 working days and submit to: (all numbers are 24-hours/day) Employment & Human Services Department 1-877-881-1116 Children & Family Services Screening Unit 400 Ellinwood Way Pleasant Hill CA 94523 B. To Report Elder Abuse: If the alleged abuse has occurred in a long-term care facility Complete a Suspected Dependent Adult/Elder Abuse Form (SOC 341) Call Ombudsman Services of Contra (available online at Costa (925) 685-2070 to make a http://www.dss.cahwnet.gov/cdssweb/entres/forms/English/SOC341.pdf) verbal report within 2 working days and submit to: Ombudsman Services of Contra Costa 24-Hour Crisis Line: 1601 Sutter Street, Suite A 1-800-231-4024 Concord CA 94520 If the alleged abuse has occurred anywhere else Complete a Suspected Dependent Adult/Elder Abuse Form (SOC 341) (available online at Call Adult Protective Services http://www.dss.cahwnet.gov/cdssweb/entres/forms/English/SOC341.pdf) (925) 602-4179 within 2 working days and submit to: 1-877-839-4347 Employment & Human Services Department to make a verbal report Adult Protective Services 500 Ellinwood Way, 3 rd Floor Pleasant Hill CA 94523

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EMS Policy Manual - Contra Costa Health Services EMS Policy Manual - Contra Costa Health Services