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3888 Exposure Report Form
Please fill out this form completely, following the same criteria as if you were filling out the hardcopy forms in the firehall, anytime you encounter an 'on-the-job exposure.'
This form will be submitted directly to the Health & Safety Committee Chair.
Name
*
First
Middle
Last
Employee #
*
Apparatus (or Work Location if not in Operations)
*
Incident Date
*
MM
/
DD
/
YYYY
Incident Number
*
Incident Concern
Smoke/Fire
Hazmat
Medical
Acute Psychological Trauma
Physical Trauma
Repetitive Stress
Choose all that apply
How were you exposed?
Inhalation
Ingestion
Skin Contact
Eye Contact
Mucosal Membrane
Other
Choose all that apply
Length of Exposure
Choose Length
Less than 1 Hour
1-2 Hours
3+ Hours
Name of Chemical(s) if known
Name of Infectious Disease if known
Psychological Trauma Exposure type
EAP/CIS contact?
Yes
No
EAP/CIS Contact Name
First
Last
Medical treatment, if any, explain
Name of Attending Physician
First
Last
WSIB Forms Completed. Please note that From 6 can and should be filled out for near-miss situations where you did not need immediate medical attention.
Form 6
Supervisory Report
Decontamination if any, explain
Names of Co-workers at time of incident
Other Agencies Responding
Other Information
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