"*" indicates required fields Incident Number*Entry* Yes No Incident Date* MM slash DD slash YYYY Time on scene* Hours : Minutes Address*Site Contact*Occupant Present* Yes No Occupant NameOccupant EmailOn Duty Bat/LT/Chf*- Please Select -David CooperJeff EitelTraci KuzminskiChris LutzSteve SageJeremy StrongJosh WilsonTrent ZiegertMonitor/Operator*O2 reading (%)*Flammable Limits LEL (%PPM)*Hydrogen Sulfide (H2S)*CO reading (%)*Alarm Sounding on Arrival?* Yes No Smoke or CO Detector* Smoke Detector CO Detector Was Structure Ventilated?* Yes No Was CO Detector Present?* Yes No CO Detector ModelCO Detector MakeCO Detector Serial NumberCO Detector Date MM slash DD slash YYYY CO Symptoms* Yes No Symptoms Listed Headache Fatigue Nausea Dizziness Confusion Vomiting Feeling Ill Skin Color Red Cheeks Furnace LocationFurnace PPMFurnace Vented Yes No Water Heater LocationWater Heater PPMWater Heater Vented Yes No Chimney LocationChimney PPMChimney Vented Yes No Portable Heater LocationPortable Heater PPMPortable Heater Vented Yes No Flue Vent Pipe LocationFlue Vent Pipe PPMFlue Vent Pipe Vented Yes No Wood Stove LocationWood Stove PPMWood Stove Vented Yes No Kitchen Stove LocationKitchen Stove PPMKitchen Stove Vented Yes No Gas Dryer LocationGas Dryer PPMGas Dryer Vented Yes No Barbeque Grill LocationBarbeque Grill PPMBarbeque Grill Vented Yes No Car in Garage LocationCar in Garage PPMCar in Garage Vented Yes No Operating Fireplace LocationOperating Fireplace PPMOperating Fireplace Vented Yes No Other Gas Appliance LocationOther Gas Appliance PPMOther Gas Appliance Vented Yes No This report is to advise you that a reading of between 0 & 30 ppm of Carbon Monoxide was detected at your home/business. If any occupants are experiencing symptoms, you are advised to seek help. Be advised that younger children, pregnant women and older adults with respiratory or heart problems will be effected by Carbon Monoxide gas at significantly lower levels. It is recommended that you have a reliable heating/appliance contractor check your appliance. If no symptoms are noted and source cannot be found, occupants may re-enter the premises. Be advised that a Carbon Monoxide reading between 31 & 69 ppm was detected and with your consent the gas service, or suspected appliance has been removed from service. If any of the occupants have any health problems as described above, you need to seek medical help. Before the suspected appliance is returned to service, you need to have a reliable heating/appliance contractor check your appliances. If a vehicle or lawn appliance was the cause, it should be turned off and the occupancy ventilated.Be advised that a Carbon Monoxide reading above 70 ppm was detected and for your safety you’re asked to IMMEDIATELY evacuate your home/business. The gas service or suspected appliance has been shut off. You should NOT re-enter the home/business until this hazardous situation has been corrected. Should you need assistance with shelter, please advise and we will help you obtain shelter through the American Red Cross or other agencies. If a vehicle or lawn appliance was the cause, it should be turned off and the occupancy ventilated. PhoneThis field is for validation purposes and should be left unchanged. Δ
