This page has supporting forms that are frequently used with respect to Infection Prevention and Control. Some are actual Clinical Documents that can be used in patient charts while others are useful tools used by Health Care Workers (HCW) throughout VIHA's Acute and Residential Care sites. All forms are in PDF format.
ARO Screening Questionnaire
This form is used when patients are admitted to an Acute Care facility. It directs staff as to precautions needed and room type required. This manual form is to be used only when the electronic Clinical Documentation system is down
Infection Precaution Assessment
This form is used when patients are admitted to an Acute Care facility. It identifies risk factors and the type of precautions that can be implemented. This manual form is to be used only when the electronic Clinical Documentation system is down. A copy must be faxed to your Infection Control Practitioner
Influenza Vaccination and Prophylaxis Tracking Sheet
This sheet allows staff to track which patients have received their Influenza Vaccine and records important information with regards to the medication
Daily Infection Control Surveillance Sheet
This sheet helps staff at long term care facilities to easily track patient symptoms, the onset date as well as the type of precautions those patients are on. Staff can then quickly and effectively convey this information to their Infection Control Practitioner
Bristol Stool Chart
This form is used by HCW in Acute and Residential Care Sites to track patient stool type and output. It is used for reporting purposes and remains in the patient's/resident's chart