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Exposure Report
Burlington Professional Firefighters Association
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FIRST NAME
*
LAST NAME
*
EMAIL
*
BFD OCCURRENCE #
*
INCIDENT ADDRESS
*
DATE OF OCCURRENCE
*
STATION
*
Station 1
Station 2
Station 3
Station 4
Station 5
Station 6
Station 7
Station 8
VEHICLE RESPONDING ON
*
TYPE OF INCIDENT
*
Medical
Fire
Motor Vehicle Collision
Haz Mat
High Angle Rescue
Water Rescue
Carbon Monoxide
Training
Other
OTHER TYPE OF INCIDENT
*
LENGHT OF EXPOSURE
*
Under 1 hour
Between 1 to 4 hours
Over 4 hours
TYPE OF EXPOSURE
*
Inhale
Ingest
Skin Contact
Mental Health
Other
OTHER TYPE OF EXPOSURE(S)
*
DECONTAMINATION
*
Yes
No
DESCRIBE DECONTAMINATION EFFORT
*
KNOWN CHEMICALS OR INFECTIOUS DISEASE.
*
Yes
No
IF KNOWN LIST CHEMICALS AND/OR INFECTIOUS DISEASE.
MEDICAL ATTENTION RECEIVED.
*
Taken by ambulance
Taken by BFD to emergency
Walk-in clinic on duty
Emergency off duty
Family doctor off duty
No medical aid required
PROVIDE BRIEF DESCRIPTION OF MEDICAL AID RECEIVED.
*
IF MEDICAL AID RECEIVED PROVIDE DOCTORS NAME.
*
WAS THIS A LOST TIME INJURY?
Yes
No
DID YOU RECEIVE PSYCHOLOGICAL OR OTHER TYPE OF COUNSELING RELATED TO THIS EVENT?
*
Yes
No
SUMMARY OF ABOVE TREATMENT RECEIVED.
LIST OF NAMES OF INDIVIDUALS ON CREW.
*
DATE OF FORM COMPLETION
*
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