Carbon
Monoxide is an odorless, tasteless, colorless gas that is DEADLY.
It is the by-product of a fuel burning process. It can cause symptoms that can mimic flu,
unconsciousness and even death. Many
appliances around the home are capable of producing Carbon Monoxide when faulty
or unusual conditions exist. Since the source may be transient in nature, the
source may not always be detectable.
The
Ennis Fire Department responded to investigate a possible Carbon Monoxide
problem at: Time:_____ hours.
Location:____________________________________________________
on ____/___/200__.
CARBON MONOXIDE ٱ was ٱ was not found by our
instruments. Our instruments found the
highest interior level of CO to be ____ PPM.
9 PPM or less: Our instruments did not detect elevated levels at this time. However, this does not mean that higher levels did not exist prior our arrival nor that higher levels will not accumulate after our departure. Check your carbon monoxide detector per manufacturer recommendations, and replace or reset the detector as directed by the manufacturer.
More than 9 PPM: Our instruments have detected potentially dangerous
levels of carbon monoxide. We recommend
that you leave this building immediately.
We feel that it is unsafe to reoccupy this building until repairs are
made and your detector is replaced or reset as directed by the manufacturer.
100 PPM or greater: We have detected
a potentially lethal level of carbon monoxide in your home. Leave your building immediately. It is not safe until repairs are made or the
source is found and corrected. Gas to your building has been cut and will not
be approved for reconnect until repairs have been made by a licensed
technician. Replace or reset your detector as directed by the
manufacturer. Carbon monoxide affects
individuals differently depending on size, age and medical history of the
occupants. Therefore, families with young
children or members with medical conditions, or aged individuals should take
extra precautions in the event that carbon monoxide is detected.
Issued
By: _______________________________ Badge# ________ on
____/____/200__.
Received By: ____________________________________________
on ____/____/200__.
LOCATION:
_____________________________ DATE: ____/____/200__
INCIDENT
#: _________
QUICK CHECKLIST SYMPTOMS:
Yes No
Headache
ٱ ٱ
Fatigue
ٱ ٱ
Nausea
ٱ ٱ
Dizziness
ٱ ٱ
Confusion ٱ ٱ
Are
any occupants of the residence feeling ill ? ٱ
Yes ٱ No
if yes, do they feel better when away from the house ? ٱ Yes ٱ
No
Since the detector's alarm went off, what have you done ?
________________________________________________________________________________________
Shut-off carbon monoxide
sources? ٱ Yes ٱ No
If yes, which one ?
________________________________________________
Let in fresh air ? ٱ Yes ٱ
No
If yes, how and for how
long ? ____________________________
Location PPM
Chimney: Clogged flue, blocked
opening ________ _____
Fireplace: Gas or Wood ________ _____
Portable Heater: Emissions ________ _____
Gas Refrigerator: ________ _____
Kitchen Stove: ________ _____
Cook-top Vent: ________ _____
Gas Dryer: ________ _____
Water Heater: Chimney
pipe ________ _____
Furnace: Flue, pipe, heat
exchanger ________ _____
Barbecue Grill: In enclosed area ________ _____
Car Garage: Car started or ran recently ________ _____
Operating Fireplace: Possible downdraft ________ _____
Carbon monoxide Detector: Make:
_____________________________________
Model:
_____________________________________
Serial #:
____________________________________