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Mater Hospital Ebola Self Reporting
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Title
Dr.
Fr.
Miss.
Mr.
Mrs.
Ms.
Prof.
Sr.
Firstname
Surname
Contact Telephone Number
Date:
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Year
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Date that you entered Unit
Time that you entered Unit:
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Time that your duty finished:
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Symptoms Experienced:
✻
Fever
Nausea/Vomiting
Diarrhea
Headache
Joint or Muscle Pain, or both
Abdominal (stomach) Pain
Lack of Appetite
Weakness
(Select as appropriate)
If you experienced any of the above, please define below the symptom, the date of onset and the duration of same:
If Fever is exhibited, what body temperature is recorded? (celcius)
.degs
Have you submitted an Employee Incident Report?
Yes
No
Have you contacted the Consultant in Occupational Medicine or the Department of Occupational Medicine CNM for personal consultation/triage prior to leaving the Unit?
Yes
No
Please Note:
• If you are symptomatic, do not leave the Unit until consultation with a Department of Occupational Medicine Medical / Nursing staff member. • If you are unable to work an assigned shift, you are required to notify the unit director of the National Isolation Unit as well as Department of Occupational Medicine. You are required to report any fever of > 37.8 degrees C, for any of the following symptoms (headache, joint / muscle aches, weakness, diarrhoea, vomiting, stomach pain or lack of appetite) for 21 days from the last contact with the index case. Any health care provider (including lab and waste handlers) is required to monitor their temperature twice daily and monitor for any symptoms (listed above) on days not worked on the Unit. Report these symptoms immediately to Department of Occupational Medicine. Compliance Statement • Department of Occupational Medicine nurses will manage the symptom-monitoring data, and the Consultant in Occupational Medicine will audit the data on a daily basis. • The Department of Occupational Medicine nurse will review data on a daily basis and make contact with any direct-care provider who does not have a temperature and symptom review documented twice a day for 21 days from the last day worked on the unit. • Once contact is made with noncompliant providers, the Department of Occupational Medicine nurse will review symptoms with the provider and log the results on their behalf. • Executive Management will be provided the names of any provider that has three instances of noncompliance.
