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Cardiac Incident Survey
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1.
Where were you when the incident occurred?
(Required.)
On scene
At station
On the way home
At home
Other (please specify)
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2.
Did you experience any of these symptoms (Select all that apply)?
(Required.)
Chest pain
Arms feeling heavy
Shortness of breath
Coughing
Nausea
Vomiting
Dizziness
Face grey/pale in color
Feeling clammy and sweaty
Other (please specify)
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3.
How long after onset did you wait before you or someone took action to get you help?
(Required.)
1 hour
1 day
1 week
Clear
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4.
Who took you to the hospital?
(Required.)
Supervisor
Fellow firefighter
Friend or Family member
Took myself
EMS
Other (please specify)
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5.
What was the outcome of the event?
(Required.)
Returned to work (full duty)
Returned to work (limited duty)
Went on disability
Retired
Other (please specify)
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6.
Type of firefighter
(Required.)
Volunteer
Career
Paid on-call
Volunteer on-call
EMS responder
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7.
What is your age?
(Required.)
<25
26-35
36-45
46-55
56-65
66+
8.
We'd appreciate your contact information so we may follow up with you.
Name
Department
City/Town
State/Province
Email Address
Phone Number
Current Progress,
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