| Date: |
| Name: |
| Home Address (Street or
P.O. Box): |
| City,
State, Zip Code: |
| Telephone(s): |
| Social
Security Number: |
| Gender:
M____ F____ |
| Date of Birth (or
approximate age): |
| The following
information would be useful for further medical evaluation.
Collect only if you have time to collect the information
without delaying treatment of the injured. |
| Date of
Exposure: |
| Location: |
| |
| Describe the
location where the person received his/her exposure. |
| Duration of
Exposure: |
| Did person have any open
wounds? (Yes or No): |
| Did person use
respiratory protection? (Yes or No): |
| What kind? |
| Did person eat or drink
while in the area? (Yes or No) |
| Did you find any
external contamination on the person? (Yes or No) |
| Emergency contact
information (name): |
| Address (City, State,
Zip Code): |
| Telephone: |
| Employer: |
