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 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 PartnerOther ProviderWere 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 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