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CHECKLIST FOR CARBON MONOXIDE
Location of Incident:_q
Date of incident
QUICK CHECKLIST OF OCCUPANTS,
Headache yes no Fatigue yes no
Nausea yes no Dizziness yes no
Confusion yes noT
Are any members of the household feeling ill? yes no
Do the residents feel better away from the house?yes no
Since the detector's alarm went off, what have you done?
Shut- off carbon monoxide sources yes no
If yes which sources
Let in fresh air? yes no
If yes how did you let the air in
How long did you let the air in
PPM reading ambient outside the dwelling
Highest PPM reading in the dwelling S
Carbon monoxide detector present? yes no
If yes list thZnmber of detetors locations and.make, and serial number of each below.
2.
3.
4.
Which detector(s) by number above activated?
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SOURCE CHECKLIST LOCATION PPM READING
Chimney clogged flue, blocked opening
Fireplace(s) Natural gas, LPG, Wood(indicate type for each fireplace)
Gas Appliance (if Gas Company on Scene they can perform this check)
(IF MORE THAN I OF THE FOLLOWING APPLIANCES LIST EACH ADDITIONAL
ON THE COMMENTS PAGE WITH ITS LOCATION, AND PPM READING)
refrigerator
stove
vent over stove
clothes dryer 000
water heater p
rn
fi, ace
Oilburner
bu ner
car garage
Entranceway from garage to house
Name of individual operating the CO monitor
Person completing the Checklist s m 1 k1 .► 611
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