Fire Department Fire Personnel Toxic Exposure Form - City Of Phoenix, Arizona Page 2

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FIRE PERSONNEL TOXIC EXPOSURE FORM INSTRUCTIONS
LINE:
(1-4)
Self Explanatory
(5)
Write in name of business or type of business if name not known.
EX: paper recycling facility
(6)
Put a check mark next to incident type.
(7)
Put a check mark next to activity and time spent doing that activity.
(8)
Self Explanatory
(9)
Describe smoke color(s) at time of activity during exposure.
(10)
List all substance(s), chemical(s), product(s), exposed to with attention to
correct spelling. If the substance(s), chemical(s), product(s), is unknown then
leave this section blank. The Toxic Exposure Officer will complete this
section.
(11)
Check off route of exposure. If skin is involved then list body parts exposed.
(I.E. right hand, left knee, right side of face.)
(12)
List any symptoms experienced due to the exposure. (I.E. nausea, eyes
burning, sore throat, lungs irritated).
(13,14) Self Explanatory
(15)
List what PPE was involved with the exposure and describe the
circumstances of the failure causing the exposure.
(16)
Check off
(17)
Check off where the medical treatment was rendered.

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