LOCATION OF INCIDENT:______________________________________________________ DATE:___________________

Headache     Yes     No
Fatigue         Yes     No
Nausea         Yes     No
Dizziness      Yes     No
Confusion     Yes      No

Are any members of the household feeling ill?     Yes      No
Do you feel better when away from the house?     Yes     No

Since the detector's alarm went off, what have you done?

Shut-off carbon monoxide sources     Yes     No
If yes, which ones?_____________________________________________________

Let in fresh air     Yes     No
If yes, how and for how long?____________________________________________

PPM ACCEPTABLE yes__________no__________PPM Reading________

Chimney: Clogged flue, blocked opening _______________________________

Fireplace: Gas or Wood ____________________________________________

Portable Heater: Emissions __________________________________________

Gas Refrigerator: _________________________________________________

Kitchen Stove: ___________________________________________________

Cook Top Vent: __________________________________________________

Gas Dryer: ______________________________________________________

Water Heater: Chimney pipe _________________________________________

Furnace: Gas/Oil; flue/chimney pipe ___________________________________

Barbecue Grill: In enclosed area ______________________________________

Car Garage: Car started or running recently _____________________________

Operating Fireplace: Possible downdraft ________________________________
 

Carbon Monoxide Detector: Make: Model: Serial#:
 

Officer Completing Checklist:_____________________________________________________