NAME_____________________ REG #________ LOCAL 867 EXPOSURE/INJURY/ILLNESS LOG INFORMATION The Exposure/Injury/Illness Log Information Form is to be used to record data from any fire/medical calls you attend no matter how small. Should the need arise you will have a record of all fires attended and any exposures to smoke, chemicals and fire gases and any injuries and/or illnesses. NOTE: This form is not a substitute for the Exposure Report Form/WCB Claim Form or City of Winnipeg Notification Directions for use: COLUMN 1 - Enter the date by day, month and year COLUMN 2 - Enter the time using a 24 hour clockCOLUMN 3 - Enter the Incident Number COLUMN 4 - Enter the Location of Incident COLUMN 5 - Enter the Station # in which you are working at the time of the fire/incident COLUMN 6 - Enter the apparatus you were riding on at the time of the fire/incident COLUMN 7 - Enter Fire/Medical Type by using numbers for: 1. Residential 2. Grass/Brush 3. Industrial 4. Trash/Garbage 5. Marine 6. Vehicle 7. Medical COLUMN 8 - Enter the Type of Exposure by using numbers for the following: 1. Inhaled 2. Ingested 3. Skin Contact 4. Eye Contact COLUMN 9 - Enter what you were exposed to by using numbers for the following: 1. Solids 2. Liquids 3. Vapours 4. Misc. Details COLUMN 10 - Enter type of Injury/IllnessCOLUMN 11 - Enter location of Injury/Body PartCOLUMN 12 - Enter your exposure time in minutesCOLUMN 13 - Enter if you have filled out an exposure report Yes (Y) No (N) COLUMN 14 - Enter where or whom filed with – Day Book, WCB, Etc. It is assumed that you were wearing full protective clothing and SCBA.
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