Please select the site on which the BBE occurred
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Harborview Medical Center
UW Medical Center- Montlake
UW Medical Center- Northwest
UW EH&S (UW Faculty/Staff ) & Husky Health (HSIP Students)
UW Primary Care
Harborview Medical Center
UW Medical Center- Montlake
UW Medical Center- Northwest
UW EH&S (UW Faculty/Staff ) & Husky Health (HSIP Students)
UW Primary Care
First and Last Name
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Phone number (text-enabled prefered)
Include Area Code
Please double check that your email is correct, UW email preferred
What is your preferred method of contact?
Text
Email
Phone Call
Can we leave a detailed voice message at this number?
Yes
No
Date of birth
* must provide value
Today M-D-Y
Or SID if HSIP Student
Date and time of exposure
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Now M-D-Y H:M
Are you a HSIP student?
* must provide value
Yes
No
Location of exposure at HMC
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1EH- Emergency Department 1EH-12/Resus 4 1PSB- HMHAS, OBOT 1WC- Ortho/Trauma & Aftercare Clinic 2EH- ICU 2EC-Echo Clinic and diagnostics 2PSB- Family Medicine, Abuse & Trauma Center 2WH- Neuro ICU 2W Clinics- Madison, Infectious Disease, Hansons Disease 3EH- Telemetry 3CT- Neuroscience diagnostics 3WH- Neuro Acute 3WC- Medical Specialties, Adult Med Clinic, Occ Med 4EH- Telemetry 4MB 4NJB- Sleep Center and Oto Clinics 4WH- Inpatient Rehab 4WC- Epilepsy, OMS, OTO, Optho 4EC- Acute and ICU Therapies: Occupational (OT), Physical (PT), Speech (ST) 4EC- Metro 5CT- TCU 5EH- Telemetry 5WA, 5WB, 5MB, PES- Inpatient Psych Units 5NJB- Neurosurgery, Sports/Spine 6CT- TCU 6EH- Ortho Acute 6MB- Planned Surgery 6NJB- Clinics (Foot & Ankle, Hand (HT), Outpatient Therapies) 7EH- General Surgery 7MB MCICU 7NJB- Eye Institute (Non-OR) 8EH- Acute Burns/Peds 8CT- Burn Clinic 8MB APA/Endoscopy 9EH- Burn/Pediatric ICU 9MA/9MB- Trauma ICU 9NJB- Chest, CORP, Surgery, Heme/Onc, EMG, etc 10NJB- Cardiology, Endo, GI, Hepatitis, Kidney, Vascular Clinics 11 NJB- KC Sexual Health/ STI Clinic Admitting ALNW- Airlift Northwest Angio APA- Ambulatory Procedure Area ASU/PACU Anesthesiology Boarders ED/PACU Cath Lab CPU- Central Processing (2MB) Contact Center (Downtown) Continuity of Care/ Care Management Employee Health Services (1EC) EVS/ Housekeeping Engineering and Maintainence Executive Leadership Team/ UW Med System Administration (multiple locations) Eyes on James Financial Counseling Float Pool- Acute and ICU Float Pool- Ambulatory Food and Nutrition Services Gamma Knife/ Angio (GCT) GWC- Internation/Ped/Women/Mem/Brain HIM - Health Information Management (PSB) Human Resources (PSB) IT - Information Technology/ Help Desk (multiple locations) Interpreter Services (PSB) Med Stores/ Supply Chain (BCT) NWKC - Northwest Kidney Center/ Dialysis Operating Room- Main Operating Room- NJB Operating Room- Eye Institute Lab- Chemistry Lab-Main Lab- Phlebotomy Patient Relations (GCT) Pharmacy - Inpatient Pharmacy - Outpatient Prosthetics/Orthotics Pioneer Square Clinic/Downtown programs Pulmonary Function Lab Radiology- Inpatient Radiology- Outpatient Respiratory Therapy Respite (Jefferson Terrace) Security Services Social Work Spiritual Care Telecommunications Transfusion Services Other - Main Hospital/ Maleng Building Other - Ninth & Jefferson Building (NJB) Other - Pat Steele Building (PSB)
If your HMC Location is other, please describe
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What is your role at HMC?
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Administrative ARNP Chaplain Dietary Clerk Dietician Engineer HA Housekeeping Interpreter/ Cultural Mediator IT Staff Kitchen Staff Lab Tech/Scientist MA Manager/ Supervisor MHP - Mental Health Practitioner Nurse Nutrition OT/PT PA Patient Liaison PCC - Patient Care Coordinator PCT - Patient Care Technician Peer Navigator Pharmacist Phlebotomist Pilot Provider - APP Provider - Attending Provider - Fellow Provider - Resident PSS - Patient Service Specialist Psychologist Respiratory Therapist Researcher Security Guard Speech Pathologist Social Worker Spiritual Care Student Technician/ Technologist Therapist Transporter Vendor Volunteer Other
IR Tech
Lab Tech
Surgery Tech
Other
IR Tech
Lab Tech
Surgery Tech
Other
If your role is not listed, please describe:
Please describe your role if other
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Location of exposure at UWML
* must provide value
2SE Boarding Area 2SP Boarding Area 4NE Neuro, NS 4S Special Procedures Unit 4SA Neonatal Intensive Care 4SE Tx, Renal, Vasc, Gen Sx, Obs 5E Med/Surg Transplant ICU 5NE Cardio, Surg, Tele 5S Postpartum/Newborns 5SA Cardiothoracic ICU 5SE Critical Care 6E Antepartum 6N Transfusion SVS Lab 6NE General, Fam Med 6S Antepartum 6SA Medical Onc ICU 6SE Orthopedics 7NE Med/Onc 7S Clinical Research, Boarding 7SA Tx, Renal, Vasc, Gen Sx 7SE Heme/Onc, Gyn/Onc 8N Rehab 8NE BMT Transplant 8SA Med Onc 8SE Medical Oncology Infusion Clinic, Gyn Onc Adult Autism Clinic Allergy Clinic Alvord Brain Tumor Center Ambulatory Float Pool Ambulatory Floats Anesthesiology Bone & Joint Surgery Center Bronchoscopy & Digestive Health Center Card-Diagnostic-EKG Cardiac Transplant P A Cardiology P A Cardiology Admin Cardiology Clinic 7717 Cardiology EPS LAB7715 Cath Lab Cardiology-Heart Cath Center on Human Development & Disability CHDD Clinic Lab- Chemistry Clinic Lab- Microbiology Clinic Lab- Hematology Clinic Lab- Chemistry CSPD CT Roosevelt CTR Reconstruct Surg Dermatology Center/Derm Surgery Diabetes Diabetes Care Center Digestive Health Center Eastside Specialties Center East side imaging Echocardiology Lab EEG ED - Emergency Department Employee Health Clinic Endocrine Endoscopy Cardiology EP Lab Environmental Services Environmental Services- R (Roosevelt) Eye Center Gastroenterology Genetic Medicine Clinic General Internal Medicine Headache & Outpatient Psychiatry Clinic Int Card Recovery Unit Internal Med Clinic R Kidney Dialysis Laundry and Linen Mammography-Roosevelt Maternal & Infant Care Clinic (MICC) Medical Specialties Center Men's Health Center MFM Clinic Arlington MFM Clinic Yakima Valley MLT Heart Institute Mother/ Baby PCN MRI MRI Roosevelt Neonatal ICU Neonatal NPS Neurology Clinic & EMG Neurosurgery Nuclear Medicine OR - Main OR - Pavilion OR - Roosevelt Otolaryngology & Eye PAC PACU Post Anesthesia Care Pain Clinic Pathology- Autopsy Pathology- Cytogen Pathology- EM Pathology- Histology Pediatric Care Center Perinatal Daily Phlebotomy Outpatient Plastic Surgery Center Pre-op Care Unit Pre- Surgery Clinic/PSC Radiation Oncology Radiation Angiography Radiology Radiology-Diagnostic Radiology-Roosevelt Radiology - CT Radiology - Interventional Regional Heart Center Regional Heart Center - Edmonds Rehab Med Clinic Rehab Therapy - Outpatient Reproductive Care Center Respiratory Care Services Rheumatology Roosevelt Lab Satellite lab SLU Echo Special Procedures O/P SCCA Hospital Sports Medicine Center/ Stadium Clinic Surgery Pavilion PACU Surgical Specialties Center Ultrasound Ultrasound Diagnosis Ultrasound Roosevelt Urology Clinic UWMC Pharmacy Vascular Access RN SVC Vascular Diagnostic SVC Vascular Lab Weight Loss Center Women's Health Center Other
If your location is other please describe
What is your role at UWML?
* must provide value
Administrative Chaplain Dental Resident Dental Student Dietary Clerk Dietician Engineer EVS Interpreter/ Cultural Mediator IT Staff Kitchen Staff Lab Technician MA Manager/ Supervisor MHP - Mental Health Practitioner Nurse Tech Nurse Nutrition OT/PT Other Pathologist Patient Liaison PCC - Patient Care Coordinator PCT - Patient Care Technician Peer Navigator Pharmacist Phlebotomist Pilot Provider - APP Provider - Attending Provider - Other Provider - Resident Provider- Fellow PSS - Patient Service Specialist Psychologist Respiratory Therapy Security Guard Social Worker Spiritual Care Student Technician/ Technologist Therapist Transporter Vendor Volunteer
If your UWML role is not listed, please describe
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Please provide your specialty
Location of exposure at UWNW
* must provide value
Other 1 E Oncology 2 East 4th Floor 5th Floor Admitting Adult Psychiatric Unit Ambulatory Clinic CBHL 2D/3D MSE CBHL 4D CBHL5D CBHL 6D E CBHL 6D W CBHL Annex CBHL Neuromodulation Cardiac Procedure Unit/Cath Lab Care Coordination Child Birth Center Clinical Engineering Contract Employee Daycare E-Wing Infusion ED - Emergency Department EEG/Neurodiagnostics Endoscopy EVS/Housekeeping Food service Heart Institute ICU Inpatient Pharmacy IT Staff Main Lab/Phlebotomy Main Operating Room Medical Arts Building MSE/Infusion Outpatient Surgery Center PAC - Pre Anesthesia Clinic Plant Operations Pre Surgical Admit/ Post Anesthesia Care Radiology Security Special Care Nursery Special Care Unit Starbucks Sterile Processing Stores/Materials Handling Therapies (PT/OT/Speech) Inpatient
If your UWNW location is not listed, please describe
What is your role at UWNW?
* must provide value
Barista/Food Service Worker CNA- Certified Nursing Assistant Contract staff (vendors, scribes, etc.) Engineer EVS/Housekeeping Interpreter/ Cultural Mediator Manager/ Supervisor Medical Assistant Nurse OT/PT Other Phlebotomist Provider - Resident Provider- Advanced Practice (ARNP/PA) Provider- MD Respiratory Therapy Security Guard Social Worker Spiritual Care Student Technician/ Technologist Transporter Unit Secretary Volunteer
If your role is not listed, please describe
Location of EH&S Exposure
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Husky Health/Hall Health EH&S Dental School D wing Dental School Magnuson Park/ Sand Point Location Dental School Other Health Sciences AA Wing Health Sciences BB Wing Health Sciences RR Wing South Lake Union Other Retail Pharmacy/ Pharmacy Other
If other, please describe your EH&S Location
What is your role at EH&S?
* must provide value
Dental Assistant Dental Hygienist Dental Staff- Faculty Practice/ Staff Dentist Dental Staff- Other Health Sciences Immunization Program Students- Medical Health Sciences Immunization Program Students- Dental Health Sciences Immunization Program Students- Medical Health Sciences Immunization Program Students- Pharmacy Health Sciences Immunization Program Students- PT/OT Researcher or Principal Investigator Research Assistant or Other Support Staff Vet Staff, Vet Tech, Animal Husbandry Staff UWPD Officers Registered Nurse Medical Assistant Provider Other Sterilization Technician Medical Student- Other Nursing Student- Other Pharmacy Student Retailer- Other
If your role is not listed, please describe
Location of Exposure at UW Primary Care
Other Ballard Belltown Factoria Federal Way Issaquah KDM Lopez Northgate Ravenna Shoreline SLU Woodinville Remote Work Fremont Primary Care Mountlake Terrace OPMC
If other, please describe
What is your role at UW Primary Care?
Between Visit Coordinator (BVC) Contract staff (vendors, scribes, etc.) Dietitian Engineer EVS/Housekeeping Manager/ Supervisor Medical Assistant Nurse Other Patient Services Specialist (PSS) Phlebotomist Provider - Resident Provider- Advanced Practice (ARNP/PA) Provider- MD Security Guard Social Worker Student Technician/ Technologist
If your role is not listed, please describe
If you are a visiting resident, what is your START date?
Today M-D-Y
Where were you seen for your initial work up?
* must provide value
Employee Health
ED
Other
If other, please describe
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