Sample Exposure Report Form

Please complete all required information.  Contact Union Officer if you would like to retain a hard copy for your records.

If you are human, leave this field blank.

First Name *

Last Name *

Social Security Number *

Last 4 Digits Only

Incident Date *

Alarm Time *

Incident Number *

I. INCIDENT TYPE

Incident Type *

Trash/DumpsterVehicle FireFood On StoveResidential FireIndustrial FireCommercial FireMarine FireRailroad FireWater/RescueHazmatEMSOther

Other Type of Occurrence

II. Length Of Exposure By Fire Stage/Activity

Fire Stage

Incipient:

Less than 1 Hour

1 to 2 Hours

2 to 3 Hours

Greater than 3 Hours

Free Burning:

Less than 1 Hour

1 to 2 Hours

2 to 3 Hours

Greater than 3 Hours

Smoldering:

Less than 1 Hour

1 to 2 Hours

2 to 3 Hours

Greater than 3 Hours

Was an SCBA Used? *

Yes

No

Number of Bottles Used

123Other

III. Smoke/Chemical/Other Exposure

Smoke Conditions

Light

Medium

Heavy

None

Smoke Color(s)

Chemical/Bio-Hazard Present *

Name of chemical (if known) or type of hazard

Form *

Vapor/Gas

Light Mist

Bodily Fluids

Dust

Combust Products

Light/Heavy Mist

Solid/Powder

Type of Exposure *

*Please describe "Other" response in ADDITIONAL INFORMATION Section

Inhaled

Eye Contact

Ingested

Skin Contact

Other

Please describe

IV. Symptoms

At Incident

Eyes Burn

Nose/Lung Irritation

Ears Ringing

Unconscious

Cough

Nausea/Queasiness

Headache

Cough Blood/Nose Bleed

Dizzy

Skin Irritation/Rash

Other

Post Incident

Eyes Burn

Nose/Lung Irritation

Ears Ringing

Unconscious

Cough

Nausea/Queasiness

Headache

Cough Blood/Nose Bleed

Dizzy

Skin Irritation/Rash

Other

V. Medical Diagnosis

Did You Receive A Medical Evaluation Or Treatment After Exposure? *

YesNo

Did you File A (Exposure Report) After Exposure?

YesNo

VI. Special Equipment/Decontamination

WHERE YOU SUPPLIED WITH SPECIAL EQUIPMENT FOR THIS INCIDENT?* If yes, please describe

YesNo

Special Equipment Description

WERE SPECIAL DECONTAMINATION PROCEDURES FOLLOWED AFTER THE EXPOSURE?* If yes, please describe *

YesNo

Please describe

VII. Co-Workers Present At The Time of Exposure

Please list the Name(s) of other Firefighters Working Close to You at the Time of Exposure

VIII. Additional Information

Your Function at the Incident, Unusual Circumstances, ETC.

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