King Vision Blade Surveillance

This form is intended to assist NTRAC in surveillance of our King Vision Blade program.  Please fill out this form completely after each intubation using the King Vision device.  Do not place any protected health information on this form.  This information will be kept secure and used for process improvement and data collection only.  A completed form is necessary to obtain a replacement blade from the NTRAC program.

Q1
Q2
Q3Patient Classification:
 
Q4Reason for use:
 
Q5Number of intubation attempts:
Q6Type of blade used:
Q7Bougie:

Patient Demographics

Q8
Q9Sex:
Q10
 
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