I. MUSCULOSKELETAL: NECK PAIN____ MUSCLE TENDERNESS___ MUSCLE TREMBLING/ TWITCHING___ WEAKNESS___ PARALYSIS, DESCRIBE:_____________________ CONVULSIONS___ TREMORS___ MUSCLE ACHES___ BACK PAIN___ JOINT PAIN___
J. SKIN: RASH___ REDDENING___ ITCHING___ BLISTERS___ PAIN___ NUMBNESS___ PROFUSE PERSPIRATION___
15. COMMENTS:
_____________________________________________________________
16. ANIMALS AFFECTED: YES___ NO___ DESCRIBE:_________________
17. RELATED SPECIMENS_________________________________________
ID NUMBER_____________________________________
DESCRIPTION__________________________________
18. COLLECTOR
SIGNATURE____________________________
NAME___________________________
PHONE NUMBER______________________
E-MAIL________________________
19. REVIEWER
SIGNATURE
NAME
PHONE NUMBER_________________
E-MAIL_________________
Figure B-2. Sample/specimen background document.
CB INCIDENT INTERVIEW