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Home
Forms
Dave’s Potluck
Reports
Gear Inspection
Exposure Report
Post Trip Inspection
Equipment Checks
Rescue 1
Media
Image Upload
Information
Gear Request
Vacation Schedule
Personal Info
Personal Exposure Report
Employee's First and Last Name(s)
(Required)
Add
Remove
Incident Date
(Required)
MM slash DD slash YYYY
Incident Type
(Required)
Residential Fire
Industrial Fire
Vehicle Fire
Commercial Fire
Dumpster Fire
Marine Fire
Aircraft Fire
Wildland Fire
Transport Fire
Rescue
Haz-Mat Spill
Explosion
Railroad Incident
Training
Extrication
Other
If Other, Please Explain
Exposure Information
Length of time exposed
(Required)
Activity during exposure
Was SCBA worn
(Required)
Yes
No
If yes, how many bottles were used?
If no, why not?
What level of PPE was worn during?
Material(s) exposed to
Symptoms as a result of the exposure
Treatment (if any) required
Was it a traumatic exposure (loss of life, decapitation, emotionally disturbing, etc)?
Yes
No
If yes, explain
What you saw, what you did, what you touched, what you heard, how it made you feel and what you did to debrief immediately after the exposure
Was CISM initiated?
Yes
No
Additional Event Details
Was there a follow up treatment?
Yes
No
Signature
(Required)
Comments
This field is for validation purposes and should be left unchanged.
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