Exposure Report Form
Call the MSA/MSO immediately if you suspect an exposure has occurred. The MSA is MFD RFA's DICO. The MSA/MSO will help assist you with this process.
Reference Policy 903
I am reporting a work related:
*
Exposure
Toxic Chemical Exposure
Exposure Date:
*
-
Month
-
Day
Year
Date
Employee Name:
*
Employee Email:
*
example@example.com
Employee Number:
*
Employee # (cell):
*
Please enter a valid phone number.
Format: (000) 000-0000.
Station assignment at time of exposure:
*
Shift:
*
Time work (exposure) started:
*
Time work (exposure) ended:
*
Total time of exposure:
*
Source Patient Information
Patient's Name:
*
Gender:
*
Date of Birth:
*
-
Month
-
Day
Year
Date
Type of Exposure:
*
Bloodborne
Airborne
Toxic - For example, an EV fire
Route of Exposure:
*
Needle Stick
Mouth to Mouth
Face
Mouth
Non-intact skin
Air Borne
Bodily fluids involved:
*
Blood
Saliva/Sputum
Feces
Urine
Vomit
None
Medical device involved in exposure: (i.e. IV cath, lancet, etc.)
*
Physical location exposure occurred (i.e. Medic/Aid unit, scene location, etc.)
*
Describe exposure incident:
*
List witnesses to exposure:
*
Personal Protective Equipment
What equipment was used - check all that apply
*
Gloves
Gown
Glassess
Face Shield
PAPR/CARP
Bunker Gear
SCBA
Mask Type:
*
None
Surgical
N95
SCBA - SCOTT C5 Visions
Other
Date (Employee Signed/Submitted)
*
-
Month
-
Day
Year
Date employee submitted and signed
Signature
*
MSO on Shift:
*
BC on Shift:
*
Captain on Incident:
*
Captain's email:
*
example@example.com
DICO's email:
*
example@example.com
After completing this form click the submit button. For further documentation you may choose to complete the PIIERS documentation as well.
Submit
Submit
Should be Empty: