DATE:_____________________ INTERVIEWER: _____________________________
SUBJECT'S NAME: _____________________________________________________
ALIAS #1_____________________________ #2_____________________________
AGE:____________ SEX: ____ M ____F YEAR OF BIRTH:_________
NATIONALITY:______________________________________________
SUBJECT'S ADDRESS:_________________________________________
IDENTITY CARD #:___________________________________________
DELIVERY METHODS:
TYPE:____UNKNOWN _____GROUND ____AIR _____ARTILLERY/ROCKET ____MINE
OTHER, DESCRIBE:_______________________________
HEIGHT: ______(M)
SIZE:_____________ (AFFECTED AREA IN METERS)
DISTANCE:__________(M)
AGENT CHARACTERISTICS
ODOR: _____NONE _____SWEET _____FRUITY _____IRRITATING _____PEPPER _____FLOWER _____CHANGING _____
OTHER, DESCRIBE:___________________________
COMMENTS:____________________________________________________
_____________________________________________________________
CONSISTENCY:
______SMOKE ______MIST _____DUST _____RAIN ______GEL ______DRY ____VISIBLE ____INVISIBLE ____OTHER, DESCRIBE:_______________________
COLOR:_____________ DESCRIBE DEVELOPMENT OF COLOR:___________________
AREA COVERAGE:______________________________________________
PHYSICAL DISSEMINATION/COVERAGE (i.e., DROPLET SIZE AND DISTRIBUTION):
WRITE OR DRAW______________________________________________
SYMPTOMS:__________________________________________________
_____________________________________________________________
INDIVIDUAL'S ACTIONS:
DURING ATTACK:_____________________________________________
___________________________________________________________
AFTER ATTACK:______________________________________________
___________________________________________________________
PROTECTIVE MEASURES:_______________________________________
TREATMENT RECEIVED:________________________________________
___________________________________________________________
ENVIRONMENTAL EFFECTS: VEGETATION CHANGE? ___YES ___NO
DESCRIBE:__________________________________________________
___________________________________________________________
ANIMALS AFFECTED? ___YES ___NO
DESCRIBE:__________________________________________________
OTHERS AFFECTED:
NAME AGE SYMPTOMS RESOLUTION
___________________________________________________________
___________________________________________________________
___________________________________________________________

Figure B-3. Chemical/biological incident interview.

FM AMEMBASSY DDTTTTZ JAN 02

1.00
SHIPPING

TO CDR TEU APG MD/SMCTE-OPEI/
SECSTATE WASHDC
SECDEF WASHDC//OSD-ISA/OUS-DRE//
INFO CIA WASHDC//OSWR-STD-LSB/NIC-NIO(STP)//
JCS WASHDC//J-3/J-5//
DIA WASHDC//DT-3B/DT-5A//
DIR NSA FT MEADE MD
DIR AFMIC FT DETRICK MD//AFMIC- CR/AFMIC-SA//DA WASHDC//DAMI-FIT/DAMO-SWC//
CDR FSTC CHARLOTTESVILLE VA//AIAST-RA-ID2//
CDR CRDEC APG MD//SMCCR-OPE//
CDR USACMLS FT LEONARD WOOD MO//ATSN-CM-CO//
CDR USAMRIID FT DETRICK MD// (FOR SUSPECT BIOLOGICAL SAMPLES/SPECIMENS ONLY)

CLASSIFICATION

SECSTATE FOR...
SECDEF FOR
CIA FOR
JCS FOR J-3/J-5 FOR
DA FOR DAMO-SWC FOR
AFMIC FOR
CRDEC FOR FIO
FSTC FOR AMXST-FM
USACMLS FOR THREAT MGR
E.O. 12356: DECL: OADR (NOTE: This is included if the message is classified.)
TAGS:
SUBJECT: SHIPMENT OF CB SAMPLES
REF(S): TEU MSG, #______. (DTG DDTTTT [time zone] Jan 02)

1. INFORMATION: