EMS Exposure Reporting Fields marked with an * are required. First Name Last Name Email CSFA Member ID Incident Number Location Date of Exposure Reported To Hospital Hospital Patient Name Patient Tested Patient Carrier Details Protective Measures EMS Jacket Face Shield Gloves Worn Gown Worn Turn-Out Pants used Other How Exposure Occured Airborne Pathogens Contact w/Mucus Membrane Contact w/open, non-intact skin Cut while cleaning equipment Laceration Needle Stick Other Fire Send Message California State Firefighters' Association 440 N Barranca Ave #6164 Covina, CA 91723 (800) 451-2732 membership@csfa.net Powered By GrowthZone