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 Name Occupant Email On 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 Model CO Detector Make CO Detector Serial Number CO 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 Location Furnace PPM Furnace Vented Yes No Water Heater Location Water Heater PPM Water Heater Vented Yes No Chimney Location Chimney PPM Chimney Vented Yes No Portable Heater Location Portable Heater PPM Portable Heater Vented Yes No Flue Vent Pipe Location Flue Vent Pipe PPM Flue Vent Pipe Vented Yes No Wood Stove Location Wood Stove PPM Wood Stove Vented Yes No Kitchen Stove Location Kitchen Stove PPM Kitchen Stove Vented Yes No Gas Dryer Location Gas Dryer PPM Gas Dryer Vented Yes No Barbeque Grill Location Barbeque Grill PPM Barbeque Grill Vented Yes No Car in Garage Location Car in Garage PPM Car in Garage Vented Yes No Operating Fireplace Location Operating Fireplace PPM Operating Fireplace Vented Yes No Other Gas Appliance Location Other Gas Appliance PPM Other 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. EmailThis field is for validation purposes and should be left unchanged.