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*
Date Format: MM slash DD slash YYYY
Time of Incident

: HH

MM

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
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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