ࡱ> y{x7 "$bjbjUU X7|7|Cl$A( pt'''''''$C) c+>' >'% '%%%  '%'%%d&d&  @'ԅ0nd&d&(0A(d&+,x+d&%Santa Clara Fire Department Exposure Report Form Social Security Number: FORMTEXT       Alarm Time: FORMTEXT       Last Name: FORMTEXT       Report #: FORMTEXT       Incident Date: FORMTEXT       Incident Type (check one only)  FORMCHECKBOX  Residential Fire  FORMCHECKBOX Industrial Fire  FORMCHECKBOX Vehicle Fire  FORMCHECKBOX Commercial Fire  FORMCHECKBOX Wildland Fire  FORMCHECKBOX Trash/Dumpster  FORMCHECKBOX HazMat  FORMCHECKBOX Explosion  FORMCHECKBOX Rescue  FORMCHECKBOX Spill  FORMCHECKBOX Other FORMTEXT       Type of Occupancy  FORMTEXT       Length of Exposure by Fire Stage/Activity Fire Stage Activity: < 1 Hr 1-2 Hr. 2-3 Hr. 3+ Hr. <1 Hr 1-2 Hr. 2-3 Hr. 3+ Hr.  FORMCHECKBOX Incipient  FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX Extinguishment  FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX  Free Burn  FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX Entry/Ventilation  FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX Smoldering  FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX Rescue  FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX Non Fire  FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX Light Overhaul  FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX Heavy Overhaul  FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX EMS  FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX Investigation  FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX  Smoke/Chemical/Other Exposure (at fire, spill or Rescue Scene) Smoke Conditions:  FORMCHECKBOX  Light  FORMCHECKBOX  Heavy  FORMCHECKBOX  None Smoke Color: FORMTEXT       Chemical(s) Present Vapor Dust Heavy Light Combust Solid Comments Mist Mist Product Powder  FORMTEXT        FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX  FORMTEXT       FORMTEXT        FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX  FORMTEXT       FORMTEXT        FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX  FORMTEXT       FORMTEXT        FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX  FORMTEXT       Type of Chemical Exposure:  FORMCHECKBOX Inhaled  FORMCHECKBOX Ingested  FORMCHECKBOX Skin Contact  FORMCHECKBOX Eye Contact  FORMCHECKBOX Other FORMTEXT       If Medical exposure, name of victim, medical condition exposed to: FORMTEXT       Symptoms At Incident Symptom After Incident At Incident Symptom After Incident  FORMCHECKBOX  Eyes Burn  FORMCHECKBOX   FORMCHECKBOX  Ears Ringing  FORMCHECKBOX   FORMCHECKBOX  Cough  FORMCHECKBOX   FORMCHECKBOX  Headache  FORMCHECKBOX   FORMCHECKBOX  Cough Blood/Nose Bleed  FORMCHECKBOX   FORMCHECKBOX  Skin Irritation/rash  FORMCHECKBOX   FORMCHECKBOX  Nausea/Queasiness  FORMCHECKBOX   FORMCHECKBOX  Unconscious  FORMCHECKBOX   FORMCHECKBOX  Dizzy  FORMCHECKBOX   FORMCHECKBOX  Other FORMTEXT        FORMCHECKBOX   FORMCHECKBOX  Nose/Lung Irritation  FORMCHECKBOX  Medical Diagnosis Did you receive medical evaluation or treatment after exposure  FORMCHECKBOX yes  FORMCHECKBOX  no Diagnosis:  FORMCHECKBOX Smoke Inhalation  FORMCHECKBOX Contact Dermatitis  FORMCHECKBOX Respiratory Tract Irritation  FORMCHECKBOX Other FORMTEXT       Doctor/Treatment Facility: FORMTEXT       Special Equipment / Decontamination Where you supplied with special equipment for this incident:  FORMCHECKBOX  yes  FORMCHECKBOX no Describe: FORMTEXT       Were special decontamination procedures followed after exposure:  FORMCHECKBOX yes  FORMCHECKBOX no Describe: FORMTEXT       Co-Workers at the time of Exposure: 1. FORMTEXT       2. FORMTEXT       4. FORMTEXT       5. 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