Carbon Monoxide Alarm Report and Notice of Findings
Date______
Fire Department Name ______
Name of Officer in Charge______
Occupant Name ______
911 Address of Incident______
Upon arrival of Fire Department:
Was everyone out of the structure? yes______no______
Are any occupants feeling ill? yes______no______
Any symptoms of:
Headache ______Fatigue______Confusion______
Dizziness ______Nausea______
Did symptoms improve upon leaving residence? yes____ no_____
How many occupants?______Ages______
What appliances were being used at the time, or prior to the alarm activating?
_____Furnace - Wood____ Oil ____ Wood____ Coal____ Other_____
Forced Air ____ Hot Water ____ Other_____
_____Fireplace - Gas____ Wood______
_____Cook Stove - Gas ____ Wood_____ Electric______
_____Hot Water Heater - Gas____ Electric______
_____Clothes Dryer - Gas_____ Electric______Was Vent blocked? yes____ no____
_____Chimney - Good Condition? yes____ no____ Leaking flues? yes____ no____
_____Space Heater ______BBQ Grill______Hot Air Vents______
Any other appliances______
Did the occupant contact a competent Service Technician? yes_____ no_____
Was it suggested that the occupant contact a competent Service Technician? yes____ no____
Was a replacement CO detector sensor module or new detector installed while fire
dept. was on-scene? yes____ no_____
As the Occupant of this residence, I understand the potential hazards and dangers of Carbon Monoxide. I understand it is my responsibility to contact a competent servicetechnician to examine and repair any problems found. It is also suggested that I install a replacement detector sensor module or new CO detector alarm prior to returning to the residence sue to the dangers and effects Carbon Monoxide if undetected.
Signature of Occupant______Date______Time______
Signature of Fire Officer in Charge______Date______Time______
Explanation Sheet for Carbon Monoxide
Carbon Monoxide (CO) is an odorless, tasteless, colorless gas that is DEADLY. It is a byproduct of a fuel burning process. It can cause symptoms that mimic the flu, to unconsciousness and even death. Many combustion appliances around the home are capable of producing carbon monoxide when a fault or unusual condition exists. Since the source maybe transient in nature, the source may not always be detectable.
Any combustion process, which is not complete, will produce CO. In normal circumstances, this dangerous CO is harmlessly released into the atmosphere by means of vents, chimneys, or similar devices.
When normal venting does not occur and CO accumulates, the hazards begin. Carbon Monoxide affects many individuals differently, depending on the size and medical history of the person. Extra precautions should be taken for children and persons with medical conditionsin the event carbon monoxide was detected.
Potential CO Sources:
There are three basic types of situations that may occur which could create CO emergencies.
They are:
-Lack of adequate venting
-Improper operation of a fuel burning device which produces CO
-Failure of the venting system or device
Lack of Adequate Vents would include:
-Automobiles or other internal combustion engine operated in an enclosed area
-Open burning (BBQ grills) operated in enclosed area
-Unvented portable heaters operated in an enclosed, improperly vented area
Improperly Operating Devices would include:
- Furnace, hot water heater, gas clothes dryer or similar device not functioning properly
-Improperly installed furnace, wood or coal stove, gas fired clothes dryer or hot water heater
-Insufficient combustion air or improper flame
Venting Device Failures would include:
-Blocked or clogged vents/chimneys
-Corroded or disconnected vents/chimney
-Cracked Heat exchanger
-Leaking vent/chimney
-Improperly installed vent/chimney
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While there maybe other situations, these are the most common reasons for CO emergencies and for causing a CO detector to activate.