Exposure Reporting – Alameda Firefighters

FIRST NAME *

LAST NAME *

BFD OCCURRENCE # *

DATE OF OCCURRENCE *

STATION *

VEHICLE RESPONDING ON *

TYPE OF INCIDENT *

OTHER TYPE OF INCIDENT *

LENGHT OF EXPOSURE *

TYPE OF EXPOSURE *

DECONTAMINATION *

DESCRIBE DECONTAMINATION EFFORT *

KNOWN CHEMICALS OR INFECTIOUS DISEASE. *

IF KNOWN LIST CHEMICALS AND/OR INFECTIOUS DISEASE.

MEDICAL ATTENTION RECEIVED. *

PROVIDE BRIEF DESCRIPTION OF MEDICAL AID RECEIVED. *

IF MEDICAL AID RECEIVED PROVIDE DOCTORS NAME. *

WAS THIS A LOST TIME INJURY?

DID YOU RECEIVE PSYCHOLOGICAL OR OTHER TYPE OF COUNSELING RELATED TO THIS EVENT? *

SUMMARY OF ABOVE TREATMENT RECEIVED.

LIST OF NAMES OF INDIVIDUALS ON CREW. *

DATE OF FORM COMPLETION *

COVID 19 EXPOSURE *

Have you been exposed to anyone that has been diagnosed with Covid-19?

WHAT DECONTAMINATION TOOK PLACE? *

Detail what decontamination was conducted.