+---------------------+-----------------------+------------------------+
| Date:               | Building:             | Area/Room:             |
+---------------------+-----------------------+------------------------+
| Time of             | Time Arrive at        | Time Left Scene:       |
| Notification:       | Command Post:         |                        |
|                     |                       | \_\_\_\_\_\_\_\_\_\_   |
| \                   | \_\_\_\_\_\_\_\_\_\_  | am pm                  |
| _\_\_\_\_\_\_\_\_\_ | am pm                 |                        |
| am pm               |                       |                        |
+---------------------+-----------------------+------------------------+
| IHG Responder(s):   | At scene:             | At EOC:                |
+---------------------+-----------------------+------------------------+

+---------------+----------------------------+------------------------+
| Description   |                            |                        |
| of Chemical   |                            |                        |
+---------------+----------------------------+------------------------+
| Description   | \_\_\_Solid \_\_\_Liquid   | Type of package:       |
| of            | \_\_\_Gas                  |                        |
|               |                            |                        |
| Chemical      | Color: Odor:               |                        |
| Agent         |                            |                        |
+---------------+----------------------------+------------------------+
|               | Identity:                  | Concentration/Amount:  |
+---------------+----------------------------+------------------------+
|               | Mode of dispersion         | Current status of the  |
|               |                            | material:              |
|               |                            |                        |
|               |                            | \_\_\_opened           |
|               |                            | \_\_\_covered          |
|               |                            | \_\_dissipated         |
+---------------+----------------------------+------------------------+

+---------------+----------------------------+------------------------+
| Description   |                            |                        |
| of site       |                            |                        |
+---------------+----------------------------+------------------------+
| Description   | \_\_\_Indoors              |                        |
| of Site       | \_\_\_Outdoors             |                        |
+---------------+----------------------------+------------------------+
| Ventilation   | \_\_\_Central HVAC         | \_\_\_Running          |
|               | \_\_\_Wall A/C             | \_\_\_Off \_\_\_Sealed |
+---------------+----------------------------+------------------------+
| Access to     | \_\_\_Barricaded           | \_\_\_Occupied:        |
| site          |                            |                        |
|               | \_\_\_Caution Tape         | \_\_\_Evacuated:       |
|               |                            |                        |
|               | \_\_\_Police Control       |                        |
+---------------+----------------------------+------------------------+
| M             | \_\_\_Rain \_\_\_Sunshine  | Wind Speed:            |
| eteorological | \_\_\_Overcast             |                        |
| Conditions:   |                            | Wind Direction:        |
|               | Temp: \_\_\_\_\_\_ F C     |                        |
|               | RH%\_\_\_\_\_\_\_\_\_\_    |                        |
+---------------+----------------------------+------------------------+
| Adequacy of   |                            |                        |
| Controls and  |                            |                        |
| Containment   |                            |                        |
+---------------+----------------------------+------------------------+
| Extent of     | Building                   | People                 |
| Kn            |                            |                        |
| own/suspected |                            |                        |
| Contamination |                            |                        |
+---------------+----------------------------+------------------------+

**File Code IH105** Form 105100 9.1 Rev 10/14/05

+-------------+--------------------------------+----------------------+
| ######      |                                |                      |
|  Interviews |                                |                      |
+-------------+--------------------------------+----------------------+
| Victims/    | ###### What doe                |                      |
| Occupants   | s the container look like? How |                      |
|             |  was it opened? What happened  |                      |
|             | to you or others when exposed? |                      |
+-------------+--------------------------------+----------------------+
| First       | What type of exposure occurred |                      |
| Responders  | to people? What type of        |                      |
|             | condition are they now in?     |                      |
+-------------+--------------------------------+----------------------+
| Sig         | \_\_Coughing \_\_Burning Eyes  |                      |
| ns/Symptoms | \_\_Vomiting \_\_Nausea        |                      |
| in People   |                                |                      |
|             | \_\_Skin irritation \_\_Skin   |                      |
|             | Burns \_\_Light Headed         |                      |
|             | \_\_Dizziness                  |                      |
|             |                                |                      |
|             | Other:                         |                      |
+-------------+--------------------------------+----------------------+
| Exposure to | Airborne                       | Skin Contamination   |
| People      |                                |                      |
+-------------+--------------------------------+----------------------+

  ----------------- --------------------------------------------------------
  Site Response     
  Actions-          
  Decontamination   

  Decontamination   Time Activated:
  Facility Set-up   

  Decontamination   
  Method            

  Persons           
  Decontaminated    
  ----------------- --------------------------------------------------------

+-------------+--------------------------------+----------------------+
| IHG Role &  |                                |                      |
| Response    |                                |                      |
| Actions     |                                |                      |
+-------------+--------------------------------+----------------------+
| Hazard      | Tour of Area Site Entry by IH: |                      |
| Evaluation  | \_\_\_yes \_\_\_no Time:       |                      |
+-------------+--------------------------------+----------------------+
| PPE         | Respiratory Protection         | Protective Clothing  |
|             |                                |                      |
|             | \_\_\_SCBA \_\_\_Air Line      | SUITS Level: A B C D |
|             | \_\_\_PAPR-FF                  |                      |
|             |                                | GLOVES:              |
|             | \_\_\_Full APR \_\_\_Half APR  |                      |
|             | Cartridge:                     | FOOT:                |
|             |                                |                      |
|             |                                | FACE:                |
+-------------+--------------------------------+----------------------+
| Exposure    | \_\_Direct Reading             | Site Entry:          |
| Monitoring  |                                | \_\_\_yes \_\_\_no   |
|             | \_\_Airborne Samples           |                      |
|             |                                | Time:                |
|             | \_\_Environmental Surface Wipe |                      |
|             | Samples                        |                      |
|             |                                |                      |
|             | \_\_Personal Skin Wipes        |                      |
+-------------+--------------------------------+----------------------+
| Monitoring  |                                |                      |
| Results     |                                |                      |
+-------------+--------------------------------+----------------------+
| Rec         | PPE FOR OTHER RESPONDERS:      |                      |
| ommendation |                                |                      |
| to Others   | CONTAINMENT:                   |                      |
|             |                                |                      |
|             | CLEAN-UP:                      |                      |
|             |                                |                      |
|             | DECONTAMINATION:               |                      |
|             |                                |                      |
|             | EVACUATION OF PUBLIC:          |                      |
+-------------+--------------------------------+----------------------+