(1) the date and time of use;

(2) the location of the incident within the facility;

(3) the facts and circumstances surrounding the use of the agent;

(4) the name of the person authorizing the use of the agent;

(5) the name(s) of any person(s) on whom the agent was used;

(6) the name(s) of any facility staff involved in the use of the agent;

(7) the brand name of the agent used;

(8) the approximate amount of agent used;

(9) the approximate length of time each person was exposed to the agent from the use of the agent to initiation of decontamination procedures;

(10) the name and professional title of facility health services staff providing medical advice and assistance pursuant to the requirements of section 7063.4(d) of this Part and any treatment provided; and

(11) any adverse physical reactions of any person(s) to the use of the agent.