Healthcare Decontamination Model

HEALTHCARE DECONTAMINATION MODEL

Incident and Facility Identification

Facility Name:

Incident Report Number:    Date of Incident:    Time of Exposure:

Patient Information

Date of Birth:    Gender: Male Female Other

Phone:    MRN/ID (if applicable):

Insurance / Responsible Party

Policy Number:    Group Number:

Medical History / Baseline

Pregnant or possibly pregnant: Yes    Immunocompromised: Yes

Exposure / Contaminant Details

Decontamination Procedure

Indication for Decontamination:

Gross decontamination (initial removal of bulk contamination)
Technical decontamination (structured removal using equipment)
Dry decontamination (adsorbents/blotting)
Irrigation/continuous flushing
Antiseptic wash or soap and water
Assisted PPE doffing and inspection
Other methods:

Solutions / Agents Used:

Total Decontamination Duration:    Number of Cycles:

Risks, Benefits, Alternatives, and Acknowledgement

Explanation of Procedure: I acknowledge that the purpose of decontamination is to remove or neutralize hazardous agents on the patient and personal effects to reduce harm to the patient and to health care personnel. I have been informed in clear language of the procedure to be performed and the anticipated immediate steps.

Potential risks include, without limitation: skin irritation or chemical burns; eye irritation or injury; mucous membrane irritation; pain or discomfort during cleansing; secondary infection; hypothermia from prolonged wet exposure; allergic reaction to cleaning agents; incomplete removal of contaminant requiring additional treatments; and unforeseen complications requiring further medical care.

Benefits include removal or reduction of hazardous contamination, reduction of secondary injury, and protection of treating personnel. Alternatives include decline of decontamination (understanding the risks of retained contamination), delayed decontamination pending specialized resources, or targeted site-specific decontamination only. Refusal or delay may increase risk of harm.

The patient has the right to withdraw consent for decontamination at any time, subject to the clinical assessment of treating personnel and safety considerations for staff and others. Withdrawal may not be honored if immediate action is required to preserve life or prevent spread of contamination.

Consent and Authorizations

By signing below I certify that I have read or have had read to me the explanations above, that my questions have been answered to my satisfaction, and that I authorize qualified health care personnel to perform the above-described decontamination procedures.

I consent to proceed with decontamination as indicated.

I consent to photographs or recordings necessary for medical care or documentation. (If declined, photograph/documentation will be limited to what is essential.)

I consent to transport to another facility if clinically required for further decontamination or treatment.

I authorize release of health information to treating facilities, receiving personnel, and public health authorities as required for management of exposure and hazard mitigation.

Post-Decontamination Care and Follow-up

Provider Attestation

The undersigned facility representative attests that the information recorded on this form is a true and accurate account of the incident and the decontamination performed to the best of their knowledge.

Witness (printed name):    Witness role:

Certifications and Legal Notices

NOTICE: Decontamination procedures may require removal of clothing and the use of cleansing agents that can produce transient discomfort. All reasonable efforts will be made to preserve patient dignity and privacy. Emergency actions required to protect life or prevent the spread of hazardous agents will be taken regardless of consent, consistent with applicable law.

RELEASE AND LIMITATION: I authorize performance of the decontamination procedures described and release the facility, agents, and personnel from liability for ordinary acts performed in good faith in executing decontamination, except for willful misconduct or gross negligence. This release is limited to actions arising from the decontamination event described in this form.

CERTIFICATION: I certify that the information I have provided on this form is true and complete to the best of my knowledge.

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