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MAB Eligibility
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Clinician Full Name & Title
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Address Tx being given
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Select all that Apply
• • •
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Is Patient Pregnant?
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Symptom Onset/Exposure Date
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Date of Positive Test
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Patient Vaccinated?
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Vax Brand
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Date of last dose
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Patient on Home O2?
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Baseline O2 Ex: "2 LPM"
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Patient O2 requirement increased?
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Current O2 requirement Ex: "4 LPM"
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Initial Vitals
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Time of Vitals
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Temp in F
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Heart Rate
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SpO2
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Resp Rate
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Blood Pressure
/
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ONLY if pt NOT eligible/stable for Tx
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If patient not stable - reason
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Was 911 Called?
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Time 911 Called
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Was Patient Transported to ED?
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"Department" at "Time"
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MAB Procedure
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Please choose only one situation that applies below.
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REGEN-COV In-Office COVID +
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REGEN-COV In-Office Exposure
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REGEN-COV In-Home COVID+
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REGEN-COV In-Home Exposure
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ELI-LILLY In-Office COVID+
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Eli Lilly In-Office Exposure
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ELI-LILLY In-Home COVID+
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Eli Lilly In-Home Exposure
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Sotrovomab In-Office
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Sotrovomab In-Home
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MAB Lot #
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MAB EXP Date
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MAB Lot #
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MAB EXP Date
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Please choose only one route of treatment below.
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Infusion Treatment
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SubQ Treatment
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MAB Infusion
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IV Cath Size
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Micron Filter?
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IV Location
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IV Location Image
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Infusion Start Time
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Infusion End Time
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MAB SubQ
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SubQ Needle Size
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Time Administered
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SubQ Locations
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SubQ Location Image
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MAB Treatment - Monitoring
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Vitals - Second Set
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Time of Vitals
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Temp in F
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Heart Rate
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SpO2
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Resp Rate
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Blood Pressure
/
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Vitals - Third Set
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Time of Vitals
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Temp in F
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Heart Rate
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SpO2
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Resp Rate
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Blood Pressure
/
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Vitals - Fourth Set
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Time of Vitals
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Temp in F
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Heart Rate
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SpO2
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Resp Rate
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Blood Pressure
/
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Patient Monitored for 1hr after?
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Adverse Reactions?
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Clinician Notes:
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Adverse Reaction Reporting
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Reaction(s) Observed
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Time RXN Observed
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911 Called?
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Time 911 Called
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PT Transported to ED?
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Department at Time
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RXN Meds Used?
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Supplemental O2
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O2 device & LPM
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Adrenaline 0.3mg
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Adrenaline Route & Time
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Solu-Medrol 125mg
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Solu-Medrol Route & Time
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Benadryl 50mg
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Benadryl Route & Time
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Did PT condition improve?
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PT Condition Comment
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