BPPA Exposure Form
Form is to collect information on members of the BPPA who have been exposed to hazardous conditions
Email address
*
example@example.com
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Area / District
Incident Number
*
Incident Location
*
Incident Type
*
Officer's Name
First Name
Last Name
Officer's ID#
Assigned District / Unit
Nature of Exposure
Please Select
Blood
Saliva
Feces
Urine
Drugs
Needles
Smoke/Fire
Hazardous Material
Toxic Gas
Infectious Disease
Other
Other
If "Other" Please Specify
Source of Exposure
Please Select
Victim
Suspect
Medical Assist
Other
Other
If "Other" Please Specify
What Precautions Did You Take?
Please Select
Nitrile Gloves
N 95 Mask
Tyvek Suit
Gas Mask
Riot Helmet
Riot Gear (Turtle)
Extrication Shield
Eye Protection
None
Other
Other
If "Other" Please Specify
Was a Report Submitted?
Please Select
Yes
No
What Type of Report?
Please Select
Incident Report
Form 26
State Exposure Form
What Type of Treatment Did You Perform/Receive?
Please Select
Hand Washing / Sanitize
EMS
Hospital
Other
Other
If "Other" Please Specify
Did You Go Out Injured?
Please Select
Yes
No
Narrative
A copy of your responses will be emailed to the address you provided.
Submit
Should be Empty: