TRIAGE FORM.pdf - PLGU

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TEMPLATE FOR QUICK TRIAGE FORM FOR RETURNING EMPLOYEES (APOR AND NON-APOR) POST-COMMUNITY QUARANTINE Form Number: ________ (indicate pre-assigned serial numbers) Name of Office/Agency: ____________________________ Date and Time of Arrival of Employee:___________________ Name of Employee: ___________________________ Temperature: ____ Division/Unit: ________________ Name of Triage Officer: _________________ A. CURRENT INFORMATION: (Please ensure that all information is made available) Exposure History: 1. Where did you live in the past two weeks? Write complete address. (If the employee had resided in multiple areas, write complete address of all areas indicating the exact dates of residence.) _______________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________ Is/Are this/these area/s included in the list of areas with confirmed COVID-19 cases? (Triage officer refers to list provided by the Regional Epidemiology and Surveillance Unit or RESU.) ( ) Yes ( ) No 2. In the past two weeks, have you: Indicate “√” if “YES” or “x” if “NO” 2.1 ( ) Provided direct care for a lab-confirmed COVID-19 patient? 2.2 ( ) Worked together or stayed in the same close environment as a COVID-19 patient? 2.3 ( ) Traveled together with a lab-confirmed COVID-19 patient in any kind of vehicle or conveyance? 2.4 ( ) Lived in the same household as a lab-confirmed COVID-19 patient? Page 1 of 5 B. SIGNS AND SYMPTOMS: Interview the employee for the presence of the following signs and symptoms: (If there are any “yes” responses, ask when the symptom started.) (1) (2) (3) Signs/Symptoms (There Presence or absence of signs Date of onset of symptom/s may be more than one) and symptoms (indicate “√” (write “N/A” if “x” in for presence, or “x” for Column 3) absence) Sore/painful throat Colds or runny nose Cough Headache Fever (temperature above 37.6℃) Difficulty of breathing Other symptoms (i.e. Other symptoms (Pls. write Date of onset of each headache, fatigue, body down) symptom pains, diarrhea), if any: please indicate specific symptom in Column 2 and write corresponding date of onset in Column 3 Page 2 of 5 C. DECISION TABLE These decisions shall apply to ALL employees, whether APOR or non-APOR. Triage Officer shall check only one decision below and perform the corresponding action. (Reference: Department Memorandum No. 2020-0187, “Must-know COVID-19 Issuances and Materials as of April 20, 2020) CONDITIONS CLASSIFICATION ACTION (All conditions must be present) (-) fever and cough or colds, Not COVID-19 √ Human Resource Division (-) travel history to a place to allow employee to time in with local transmission, and to report to work (-) reside in area with √ Daily self-monitoring or COVID transmission, and HRMD monitoring and (-) exposure to COVID-19 documentation for fever, case cough or colds (+) fever and cough or colds, Not COVID-19 √ Human Resource Division (-) travel history and to refer employee to a (-) exposure to COVID-19 primary care provider of case choice for appropriate management √ May report to work once cleared by a physician as “fit to work.” (-) fever and cough or colds, Person Under Monitoring √ Human Resource Division (+) travel history from a to conduct employee to their place with local respective Barangay Hall for transmission of COVID-19 documentation and daily in the past 14 days, and/or, monitoring by the BHERT, (+) resides in area with local and transmission of COVID in √ Employee to undergo 14- the past 14-days day quarantine, at either, at home (if quarantine residence is compliant to quarantine standards) or in a designated facility (-) fever and cough or colds, Close contact of COVID-19 √ Human Resource Division (+) prolonged, close contact case to refer employee with a confirmed case of immediately to PESU for COVID-19 contract tracing √ Employee to be quarantined and monitored for 14 days in a designated community quarantine Page 3 of 5 facility or at home, if quarantine residence is compliant to quarantine standards √ Employee should be brought immediately to Panopdopan District Hospital for confinement (+) fever and cough or colds, COVID-19 Suspect √ Bring employee for (+) travel history from a immediate triage to the place with local Panopdopan District transmission of COVID-19 Hospital or to the hospital of choice for triage and appropriate management (Employee needs to be confined in hospital or in Temporary Treatment and Monitoring Facility) (+) fever and cough or colds, Close contact of COVID-19 √ Immediately refer to (+) close prolonged contact case Panopdopan District with a confirmed case of Hospital for confinement COVID-19 and/or referral D. CLASSIFICATION OF EMPLOYEE: Based on the classification in the Decision Table above, the employee is hereby classified as (write down the classification): ____________________________________________________________ E. ACTIONS TO BE DONE: ____________________________________________________________ ____________________________________________________________ NAME AND SIGNATURE OF RESPONSIBLE OFFICER ____________________________________ YOU HAVE REACHED THE END OF THE TRIAGE PROCESS. TO BE READ AND SIGNED BY THE EMPLOYEE: Page 4 of 5 DECLARATION: I hereby certify that the above information is true and complete. I understand that my failure to answer, or any false or misleading information is given by me may be used as a ground for the filing of cases against me under Articles 171 and 172 of the Revised Penal Code of the Philippines, or Republic Act No. 11332, otherwise known as the “Law on Reporting of Communicable Disease.” (Ako ay nagpapatunay na ang mga impormasyon na aking binigay ay totoo at kumpleto. Naiintindihan ko na kung anumang maling impormasyon ay maaring maging dahilan para sa paghain ng kasong kriminal laban sa akin sa ilalaim ng Articles 171 at 172 ng Revised Penal Code o sa ilalaim ng Republic Act No. 11332.) ___________________________________ EMPLOYEE'S SIGNATURE OVER NAME (PANGALAN AT PIRMA) __________ DATE (PETSA) Page 5 of 5