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Brampton Professional Fire Fighters


Brampton Professional Fire Fighters Association Exposure Report

Please complete the entire form in it's entirety.

Member Information:

Badge Number:*
Name:*
Please submit a valid email address to receive a copy of the form.*

Address:

Street:*
City:*
Province:*
Postal Code:*
Date of Birth:*
Please use M-D-Y format
Station:*
You can only select 1 choice.
201
202
203
204
205
206
207
208
209
210
211
212
213
214
Training
Fire Life Safety
Fire Prevention
Communications
Maintenance

Exposure Details

Time:*
Time of Day for exposure
Incident Date:*
Date of Incident being reported.
Occurrence Number:*

DISCLAIMER

Please complete all details related to the exposure.

Type of Exposure being Reported:*
You can only select 1 choice. If there is more than 1 you will need to complete a separate exposure form.
Haz-mat (Structure Fires, MVC's etc)
Medical
Traumatic Mental Stress
Live Fire Training (Tower, Flashover, etc)
Noise Exposure
Incident Location:*
Occupancy of Building:*
List of Chemicals Involved:*
Length of Exposure:*
Describe Incident:*
Describe your activites during Incident:*
List PPE used:*
Bunker Gear
Balaclava
Helmet
FF Gloves
Boots
SCBA
N95 Mask
Medical Gloves
Safety Glasses/Goggles
Other
Type of Exposure*
Inhaled
Ingested
Skin Contact
Eye Contact
Other
Were decontamination procedure's followed?*
You can only select 1 choice.
Yes
No
Describe Decon:*
Describe any symptoms experienced*
Did you receive medical treatment?*
You can only select 1 choice.
Yes
No
Location, Date, Time and Doctor Information:*
If Exposure is Medical in nature, Please list type if known:*
N/A
Hepatitis A
Hepatitis B
Hepatitis C
HIV/Aids
Tuberculosis
Meningococcal Disease
M.R.S.A.
Other
If Exposure is Medical in nature, How did Exposure occur?*
N/A
Needlestick or Puncture
Body Fluid splashed in mouth or eyes
Laceration of Skin
Broken Skin
Rash or Chapped
T.B. patient coughing
Human or Animal bite
Other
Was Infection Control Officer Contacted?*
You can only select 1 choice.
Yes
No
Was the Peer Support Team notified?*
You can only select 1 choice.
Yes
No

Note: * indicates required information.

 

 
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