If you are human, leave this field blank.BRAMPTON PROFESSIONAL FIRE FIGHTERS ASSOCIATION EXPOSURE REPORTMEMBER INFORMATION- PERSONALMEMBER INFORMATIONBFES Badge # *First Name *Last Name *Email *Please submit a personal email address. (Cannot be a work email address) Phone *Address *CountryUnited States (US)United Kingdom (UK)CanadaAustralia---AfghanistanÅland IslandsAlbaniaAlgeriaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAmerican SamoaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelauBelizeBeninBermudaBhutanBoliviaBonaire, Saint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBritish Virgin IslandsBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongo (Brazzaville)Congo (Kinshasa)Cook IslandsCosta RicaCroatiaCubaCuraÇaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqRepublic of IrelandIsle of ManIsraelItalyIvory CoastJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacao S.A.R., ChinaMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorwayOmanPakistanPalestinian TerritoryPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalQatarReunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Martin (Dutch part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSan MarinoSão Tomé and PríncipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia/Sandwich IslandsSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUruguayUzbekistanVanuatuVaticanVenezuelaVietnamWallis and FutunaWestern SaharaWestern SamoaYemenZambiaZimbabweCityStateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict Of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces (AA)Armed Forces (AE)Armed Forces (AP)American SamoaGuamNorthern Mariana IslandsPuerto RicoUS Minor Outlying IslandsUS Virgin IslandsZip codeDate of Birth *Station/ Division *You can only select 1 choice.Station 201Station 202Station 203Station 204Station 205Station 206Station 207Station 208Station 209Station 210Station 211Station 212Station 213Station 214Apparatus & MaintenanceCommunicationsFire Life SafetyFire PreventionTrainingShift *You can only select 1 choice.Staff DivisionA PlatoonB PlatoonC PlatoonD PlatoonINCIDENT DETAILSINCIDENT DETAILSOccurrence Number *Incident Date *Time of Incident *Incident Location *CountryUnited States (US)United Kingdom (UK)CanadaAustralia---AfghanistanÅland IslandsAlbaniaAlgeriaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAmerican SamoaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelauBelizeBeninBermudaBhutanBoliviaBonaire, Saint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBritish Virgin IslandsBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongo (Brazzaville)Congo (Kinshasa)Cook IslandsCosta RicaCroatiaCubaCuraÇaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqRepublic of IrelandIsle of ManIsraelItalyIvory CoastJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacao S.A.R., ChinaMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorwayOmanPakistanPalestinian TerritoryPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalQatarReunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Martin (Dutch part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSan MarinoSão Tomé and PríncipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia/Sandwich IslandsSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUruguayUzbekistanVanuatuVaticanVenezuelaVietnamWallis and FutunaWestern SaharaWestern SamoaYemenZambiaZimbabwePlease list the Name(s) of other crew members on this call? *EXPOSURE DETAILSEXPOSURE DETAILSType of Exposure being Reported? *Please select the type of exposure being reported.Contagious Emergency/ COVID-19Haz-mat (Structure Fires, MVC's etc.)MedicalTraumatic Mental StressLive Fire Training (Tower, Flashover, etc. )Fire InvestigationsNoise ExposureList of Chemicals Involved? *Please enter N/A if not applicable.Length of Exposure? *Please enter the length of your exposure. If the exposure is for 15 minutes please enter 00:15 Was an SCBA Used? *YesNoNumber of Bottles Used *N/A123Describe the Incident *Describe your activities during the Incident. *List the PPE you usedBunker GearBalaclavaHelmetFF GlovesBootsSCBACloth Face CoveringSurgical MaskN95 MaskAV-3000 MaskMedical GlovesSafety Glasses/ GogglesFaceshieldOtherIf you select other please indicate the type of exposure in the other input area.Other type of PPE usedType of Exposure? *InhaledIngestedSkin ContactEye ContactMental TraumaticHearingOtherIf you select other please indicate the type of exposure in the other input area.Other type of ExposurePOST INCIDENT DETAILSPOST INCIDENT DETAILSWere decontamination procedures followed?* *N/AYesNoPlease select 1 choicePlease describe DeconInput N/A if not applicable.Describe any Symptoms at the Incident? *N/AEyes BurnNose/Lung IrritationEars RingingUnconsciousCoughNausea/QueasinessHeadacheCough Blood/Nose BleedDizzySkin Irritation/RashOtherOther symptoms experienced at the Incident?Describe any Symptoms after the Incident? *N/AEyes BurnNose/Lung IrritationEars RingingUnconsciousCoughNausea/QueasinessHeadacheCough Blood/Nose BleedDizzySkin Irritation/RashOtherOther symptoms experienced after the Incident?Did you receive Medical Treatment? *N/AYesNoDid you submit a Workplace Injury/Illness Report? *N/AYesNoLocation, Date, Time and Doctor's Information *Input N/A If not applicableIf Exposure is Medical in nature, Please list type if known? *N/AHepatitis AHepatitis BHepatitis CHIV/ AidsTuberculosisMeningoccal DiseaseM.R.S.AContagious Emergency/ COVID-19OtherOther?If Exposure is Medical in nature, How did Exposure occur? *N/ANeedlestick or PunctureBody Fluid splashed in mouth or eyesLaceration of SkinBroken SkinRash or ChappedT.B. patient coughingHuman or Animal BiteOtherOther?Was Infection Control Officer contacted? *You can only select 1 choiceYesNoWas Peer Support Team notified? *You can only select 1 choiceYesNoDate Exposure Form Completed *reCAPTCHA is required.Submit
