Exposure Report Form

Sample Exposure Report Form

This form is being provided to you as a service of Local to assist you in tracking exposures to hazardous materials/environments that you encounter on a daily basis while protecting the lives of the citizens of our community. Please complete all required information. Contact Union Officer if you would like to retain a hard copy for your records.

First Name *

Last Name *

Social Security Number *

Last 4 Digits Only

Incident Date *

Alarm Time *

Incident Number *

I. INCIDENT TYPE

Incident Type *

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

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

Please describe

IV. Symptoms

V. Medical Diagnosis

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

Did you File A (Exposure Report) After Exposure?

VI. Special Equipment/Decontamination

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

Special Equipment Description

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

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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I. INCIDENT TYPE

II. Length Of Exposure By Fire Stage/Activity

III. Smoke/Chemical/Other Exposure

IV. Symptoms

V. Medical Diagnosis

VI. Special Equipment/Decontamination

VII. Co-Workers Present At The Time of Exposure

VIII. Additional Information

I.A.F.F. Local 302

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