Heat Illness Monitoring Log Form
Document observations, symptoms, and actions related to potential heat illness incidents.
Person Monitored (Full Name)
*
First Name
Last Name
Date and Time of Observation
*
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Location of Incident/Observation
*
Environmental Conditions
*
Rows
Temperature (°F/°C)
Humidity (%)
Weather Conditions
At time of observation
Sunny
Partly Cloudy
Overcast
Rainy
Windy
Humid
Other
Type of Activity Being Performed
*
Please Select
Resting
Light Work
Moderate Work
Heavy Work
Other
Observed Symptoms (Select all that apply)
*
Muscle cramps
Dizziness or fainting
Headache
Nausea or vomiting
Excessive sweating
Weakness or fatigue
Rapid heartbeat
Confusion or disorientation
Hot, dry skin
None
Other
Actions Taken
*
Moved to a cooler area
Provided water/fluid
Applied cool compresses
Called for medical assistance
Monitored vital signs
Other
Outcome/Status of the Person
*
Please Select
Returned to normal activities
Sent home to rest
Transferred to medical facility
Still under observation
Other
Additional Notes or Comments
Observer Name (Full Name)
*
First Name
Last Name
Observer Contact Information (Email or Phone)
*
Submit Log
Should be Empty: