Toxic Substances Contact Form

Name

Email Address

Phone Number

Why do you believe you may have come into contact with a harmful substance?

What was the substance?

When did this contact first occur?

Where did you come into contact with the substance?

How did the exposure affect your health?

What were you doing when you came into contact with it?

Working?

If you encountered the substance at work, do you recall any training, warnings, or provision of protective gear by your employer to protect you from or to educate you about the substance?
Yes  No 

When did you first receive medical care for the effects of the substance?

Does you physician believe your condition is related to the substance? Has your exposure occurred over a period of time?

How long?

Who owned the property where the substance is or was located?

What is the current status of your medical condition?

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