Aerosolized Procedure Notification
Incident Number
*
Identify procedures performed (Nebulizer, CPAP, Suction, BVM, Advanced Airway, CPR):
Nebulizer
CPAP
Suction
BVM
Advanced Airway
CPR
Identify Providers Present
Was the shower trailer used?
Yes
No
If trailer was used who used it?
Where there any issues with PPE? (I.E. Donning, Doffing, Malfunction)
Did the PT meet COVID-19 screening criteria or were they confirmed positive?
Screening criteria
Confirmed positive
Was a viral filter and/or ambulance ventilation system used?
Viral filter
Ambulance Ventilation
Anything else you want us to know:
Submit
Print Form
To be completed by EMS Division
Exposure Level :
None
Low
Medium
High
Further Action Needed
Yes
No
NOTES:
Should be Empty: