ix Emergency Medical Services (EMS) Rescue Squad: _________________________________ Fire Department: ______________________________________________________________ Hospital: _____________________________________________________________________ Ophthalmologist: _____________________________________________________________ Pharmacy:____________________________________________________________________ Poison Control Center: _________________________________________________________ Police Department: ____________________________________________________________ State Health Department (OH Division): __________________________________________ Toxicologist: __________________________________________________________________ Physicians, nurses, industrial hygienists, safety specialists: Name Specialty Telephone/Fax No. E-mail ________________ ________________ ________________ ________________ ________________ ________________ ________________ ________________ ________________ ________________ ________________ ________________ ________________ ________________ ________________ ________________ ________________ ________________ ________________ ________________ Employee assistance counselor: _________________________________________________ Company: ____________________________________________________________________ Address: ____________________________________________________________________ Phone No.:____________________________ Fax No.: ______________________________ E-mail: ______________________________________________________________________ Company: ____________________________________________________________________ Address: ____________________________________________________________________ Phone No.:____________________________ Fax No.: ______________________________ E-mail: ______________________________________________________________________ Name: ____________________________________________________________________ Address: ____________________________________________________________________ Phone No.:____________________________ Fax No.: ______________________________ E-mail: ______________________________________________________________________ Telephone Numbers and Information Emergency Telephone Numbers/Fax Numbers Health Care Professionals Health Insurance Carrier(s) Professional Association(s)