Sample Exposure Report Form

This form is being provided to you as a service of Local to assist you in tracking exposures to hazardous materials/environments that you encounter on a daily basis while protecting the lives of the citizens of our community.  Please complete all required information.  Contact Union Officer if you would like to retain a hard copy for your records.

Last 4 Digits Only


II. Length Of Exposure By Fire Stage/Activity

Fire Stage

III. Smoke/Chemical/Other Exposure

Name of chemical (if known) or type of hazard
*Please describe "Other" response in ADDITIONAL INFORMATION Section

IV. Symptoms

V. Medical Diagnosis

VI. Special Equipment/Decontamination

VII. Co-Workers Present At The Time of Exposure

VIII. Additional Information

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