OCCUPATIONAL EXPOSURE FORM
Demographics
Record ID:
Family Name:
Given Name:
Middle Name:
Name:
Gender:
...
Male
Female
Date of birth:
Name Of Case
*
HWC role
*
Medical Officers
Registrars
Consultant Doctors
Clinical Officers
Nurse
Laboratory Personnel
Other Health worker
Other Hospital Worker
Place of Work
*
Health facility
Non-health facility
Outpatient
Surgical Outpatient Department
Ophthalmology department
Radiology department
Neurology department
Urology department
Gastroenterology department
Orthopedic department
Referring department
Psychiatry department
Emergency department
General medicine department
Other
Caring for patients with severe acute respiratory illness in ICU
*
Yes
No
Unknown
Was the HCW caring for a patient with COVID-19?
*
Yes
No
Unknown
Was the recommended PPE used during contact with COVID-19
*
Yes
No
Unknown
Date first HCW contact with case without PPE
*
Date last HCW contact with case without recommended PPE
*
Did HCWs use PPE used during contact with this case
*
Yes
No
Unknown
Use of PPE
Surgical Mask
*
Always
Often
Infrequent
Never
N95
*
Always
Often
Infrequent
Never
Eye Protection
*
Always
Often
Infrequent
Never
Gloves
*
Always
Often
Infrequent
Never
Gowns
*
Always
Often
Infrequent
Never
Did contact with a case occur during aerosol generating procedures
*
Yes
No
Unknown
Details of aerosol generating procedures:
*
Status of contact tracing
*
ongoing
completed
lost to follow-up
Lost to follow-up details:
*
Did the contact become symptomatic
*
Yes
No
Unknown
Was COVID-19 diagnosed in this contact
*
Yes
No
Unknown
Hospital ID
*
Work ID:
*
Encounter Location:
*
Interviewer name:
*
Interviewer's ID:
*
Date of interview:
*