IR Carbon Monoxide Detector Alarm Checklist 1.2

• Select date

  Date
• Location
  Address

• Name and phone number of occupant

Questions to ask:

• Headache

  Yes

  No

• Nausea

  Yes

  No

• Shortness of Breath

  Yes

  No

• Fatigue

  Yes

  No

• Dizziness

  Yes

  No

• Confusion

  Yes

  No

• Other

  Yes

  No

• Notes

• Do they feel better when they are away?

  Yes

  No

Gas Detection Readings

• Upon Entering

• Outside Reading

• Gas Hot Water Heater

• Gas Refrigerator

• Gas Dryer

• Space Heater

• Garage

• Furnace

• Fireplace

• Other

CO Detector Information

• Make of CO Detector

• Photo

  Media

• Model of Detector

• Photo

  Media

• Serial # of Detector

• Photo

  Media

• Firefighter Handling Monitor

• Officer Completing Form