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 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*General IssueProvider InjuryDamage to Unit - Non TrafficPatient Injury or Patient Care IssueLost or Missing STEMS PropertySTEMS Equipment Damage or FailureSTEMS property damageUnit Involved*9-C9-D9-E9-F9-G9-209-A9-B9-309-31Were you, your Partner or the Patient injured?*NoYesWho was Injured?* Me (Provider Completing Form) My Partner Other Provider Were you Lifting?*NoYesPSAP 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 Select files Max. file size: 32 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. CAPTCHA Δ