JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
NWFD CoVID-19 Exposure Form
This form is to document any possible exposure as a result of CoVID-19.
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Date of Exposure:
*
MM
/
DD
/
YYYY
Incident Number (ex. F20000000 ):
*
Your answer
Unit Responded In:
*
Ambulance 109
Engine 101
Engine 102
Brush 105
Utility 10
Utility 10-1
Haz-Mat 30
Decon 30
Haz-Mat Utility 30
Personal Vehicle
Last Name:
*
Your answer
First Name:
*
Your answer
Type of Contact:
*
Direct Contact
Indirect Contact
No Contact
Type of Treatment:
*
Low Risk
High Risk (ex Nebulized Medication, CPAP, Suction, Intubation, or BVM Respirations)
Proper PPE Donned:
*
Yes
No
Comments:
Your answer
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google.
Report Abuse
-
Terms of Service
-
Privacy Policy
Forms
