Patient Details

Last Name: First Name: DOB: Gender:

Male

Female

Race: --Please select a valid choice American Indian or Alaska Native Asian Black or African American Hawaiian or Other Pacific Islander White Other Date of Exposure: Source of Exposure:

Address

Street: Address2: City: State: Alabama Alaska Arizona Arkansas California Colorado Connecticut District of Columbia Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip: Phone:

Symptoms (Check all that apply)

HeadacheDizziness WeaknessNausea Vomitting

Other Symptoms:

Carboxyhemoglobin level (cases include those 5% or higher with symptoms or 15% with or without symptoms)

Reporting Details

Reporting Institution: Reporting Clinician: Reporter's Phone: Date of Report: