Cardiac Incident Survey

Question Title

* 1. Where were you when the incident occurred?

On scene

At station

On the way home

At home

Other (please specify)

Question Title

* 2. Did you experience any of these symptoms (Select all that apply)?

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?

1 hour

1 day

1 week

Clear

i We adjusted the number you entered based on the slider’s scale.

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* 4. Who took you to the hospital?

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?

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

Volunteer

Career

Paid on-call

Volunteer on-call

EMS responder

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* 7. What is your age?

<25

26-35

36-45

46-55

56-65

66+

Question Title

* 8. We'd appreciate your contact information so we may follow up with you.

Name

Department

City/Town

State/Province

Email Address

Phone Number