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	Agency:

Q2	Date of Incident

Patient Classification:

Medical

Trauma

Other

	If other, please specify.

Reason for use:

Cervical spine stabilization

Difficult airway

Other

	If other, please specify.

Number of intubation attempts:

1 attempt

2 attempts

3 attempts

4 or more attempts

	If more than one attempt, please specify issues with intubation.

Type of blade used:

Standard

Channeled

Bougie:

Yes

Q8	Age:

Q9	Comments: