HEAT-RELATED ILLNESS WORKSHEET 2026

1. Click ‘Get Form’ to open the HEAT-RELATED ILLNESS WORKSHEET in the editor.
2. Begin by entering the patient's name and reporter details at the top of the form. This includes age or date of birth, race, and residence information such as street address, city, state, and ZIP code.
3. Fill in the date of illness and specify where the illness developed (home or work) along with the corresponding address. Include county and city details for accurate reporting.
4. Provide physician information including their name, address, and phone number. Indicate whether hospitalization occurred by selecting 'Y' for yes or 'N' for no.
5. If hospitalized, enter the hospital name and date of hospitalization. Also, include sex, week of illness, state, and if applicable, whether death occurred during this period.
6. Document any pre-existing aggravating medical factors and contributing activities such as physical exertion or substance use. Lastly, indicate if air conditioning was available during the incident.

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