Fire Department Fire Personnel Toxic Exposure Form - City Of Phoenix, Arizona

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CITY OF PHOENIX, ARIZONA
FIRE DEPARTMENT
FIRE PERSONNEL TOXIC EXPOSURE FORM
(1) NAME: ___________________________________________________________ (2) SOCIAL SECURITY #:_________________________________________
(3) INCIDENT #: ______________________________________________________ (4) INCIDENT DATE: ____________________________________________
(5) OCCUPANCY / BUSINESS NAME: ___________________________________________________________________________________________________
(6) INCIDENT TYPE: (CHECK OFF)
(a) STRUCTURE FIRE______________
(d) TRASH / DEBRIS FIRE ___________
(h) OTHER __________________
(b) VEHICLE FIRE_________________
(e) BRUSH FIRE ___________________
(i) EMS / RESCUE ___________
(c) DUMPSTER FIRE ______________
(f) EXPLOSION ___________________
(j) INVESTIGATION __________
(g) SPILL / LEAK __________________
(k) INSPECTION _____________
(7) ACTIVITY AT TIME OF EXPOSURE: (CHECK OFF)
<1HR 1HR 1-2HRS
2-3HRS
>3HRS
(a)
EXTINGUISHMENT
(b)
VENTILATION
(c)
SEARCH / RESCUE
(d)
OVERHAUL
(e)
SUPPORT ACTIVITIES
(f)
STAGING / REHAB
(g)
INSPECTION
(h)
INVESTIGATION
(i)
SUBSTANCE CONTAINMENT
(j)
EMS
(8)
SMOKE DENSITIES AT TIME(S) OF EXPOSURES (CHECK OFF)
(a) NONE _____________
(b) LIGHT _______________
(c) MODERATE ______________
(d) HEAVY ____________
(9)
SMOKE COLOR(S) _____________________________________________________________________________________________________________
(10) CHEMICAL(S), PRODUCT(S), SUBSTANCE(S), EXPOSED TO: (LIST IF KNOWN; LEAVE BLANK IF UNKNOWN)
__________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________
(11) ROUTES OF EXPOSURE: (CHECK OFF ROUTE, IF SKIN LIST AREA EXPOSED)
RESPIRATORY _________
EYE_________
INGESTION ___________
SKIN ___________
(11a) BODY PARTS EXPOSED: (I.E. RIGHT HAND, LEFT KNEE, RIGHT SIDE OF FACE)____________________________________________________________
__________________________________________________________________________________________________________________________________
(12) LIST SYMPTOMS EXPERIENCED: (I.E. SORE THROAT, EYES BURNING, LUNGS IRRITATED) __________________________________________________
__________________________________________________________________________________________________________________________________
(13) PPE WORN AT TIME OF EXPOSURE (CHECK OFF)
TURNOUTS _________
BRUSH GEAR __________
GLOVES: LATEX, NITRILE ____________
SCBA ______________
GOGGLES ____________
FIRE FIGHTING ____________
LEVEL A____________
PARTICLE MASK _______
WORK GLOVES ____________
(14) PPE MALFUNCTION (MECHANICAL) (CHECK OFF) yes____ no_____
BARRIER BREACH (CLOTHING) (CHECK OFF) yes____ no_____
(15) LIST WHAT PPE WAS INVOLVED AND DESCRIBE CIRCUMSTANCES OF FAILURE: _________________________________________________________
__________________________________________________________________________________________________________________________________
(16) DECONTAMINATION: (CHECK OFF) AT INCIDENT ____________ AT STATION__________ NOT DONE___________
(17) MEDICAL TREATMENT RENDERED: (CHECK OFF) AT INCIDENT___________ AFTER INCIDENT__________ AT HOSPITAL___________
SUPERVISOR NAME (PRINT) _____________________________________________________________________
SUPERVISOR SIGNATURE _______________________________________________________________________
COMPANY ASSIGNED TO AT TIME OF EXPOSURE______________________ SHIFT_______________________
EMPLOYEE SIGNATURE____________________________________DATE _______________________________
ARCHIVED DATE ______________________________
91-38D Rev. 10/01
DISPOSITION: WHITE—EMPLOYEE HEALTH FILE
YELLOW—ARCHIVES
PINK—EMPLOYEE
61582252849

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