Incident Report

Submit your Incident Report

Incident Report

Please Submit an incident report for any of the following (but not limited too): Accidents, violence against EMS, patient care issues, equipment damage or failure and any event outside normal EMS operations that is of concern.

Name of Provider Completing Incident Report*
First Last
Date of Incident*
MM slash DD slash YYYY
Time of Incident

: Hours

Minutes

AM/PM

Should be as close to the exact time of incident as possible.
Incident Location*
Street Address Address Line 2 City ZIP Code
Incident Category*
Unit Involved*
Were you, your Partner or the Patient injured?*
Who was Injured?*
- Me (Provider Completing Form)
- My Partner
- Other Provider
Were you Lifting?*
PSAP Number*
Description of Incident*
Describe the Incident in Detail. Were there Witnesses? Seat belts? Description of the Injury? Etc. Must be Detailed.
Upload Pertinent Pictures
Drop files here or

Max. file size: 2 MB, Max. files: 5.
DO NOT upload any Injury pictures.
Provider Signature*
By entering your name you are agreeing that the information you have entered is accurate to the best of your knowledge and understanding.
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