Carbon Monoxide Poisoning

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15/20 EXAMPLES

Text in this Example:

CARBON MONOXIDE - RELATED DEATH
NAME OF DECEDENT:
This form is to be completed in addition to the ROD form in these guidelines
WAS A CARBON MONOXIDE LEVEL RUN LOCALLY?
IF YES, LAB NAME:
LAB CONTACT & TELEPHONE NUMBER:
CARBON MONOXIDE LEVEL:
(Be sure to send copy of lab results.)
AUTOMOBILE
HOW WAS THE AUTO FOUND AND WHERE IS THE DECEDENT IN RELATION TO THE AUTO?
IS THE AUTO IN AN ENCLOSED SPACE (GARAGE, WAREHOUSE, ETC.)?
IF YES, IS/WAS THE FACILITY CLOSED OR SEALED EITHER FROM THE OUTSIDE OR THE INSIDE - EXPLAIN:
IS THE AUTO IGNITION STILL ON:
IF UNDETERMINED, EXPLAIN:
IS THE AUTO BATTERY DEAD?
IS THE GAS TANK EMPTY?
IF NO, HOW MUCH IS LEFT?
IS/WAS THE AUTO LOCKED?
DESCRIBE ALL PARAPHERNALIA (HOSES, ETC.) ATTACHED TO THE VEHICLE:
RESIDENCE
WAS INDEPENDENT AGENCY CALLED TO CHECK FACILITY FOR CO PRESENCE OR FAULTY
HEATING EQUIPMENT?
IF YES, WHICH AGENCY AND WHAT WERE THEIR FINDINGS?
DESCRIBE HEATING SOURCES:
RECENT SERVICE?
WHERE IS THE BODY FOUND IN RELATION TO THE ORIGIN OF THE CO SOURCE?
IF GARAGE IS CONNECTED TO THE HOUSE, IS THERE EVIDENCE OF CO EXPOSURE TO VEHICLE IN
GARAGE? (ANSWER ABOVE QUESTIONS RE AUTO.)
IF IN GARAGE, IS THERE A HOT WATER HEATER?
IF YES, IS PILOT LIGHT STILL LIT?
ANY OTHER SICK OR DEAD INDIVIDUALS OR ANIMALS - DESCRIBE & GIVE LOCATION IN THE
RESIDENCE:
NAME OF INVESTIGATOR
DMI#