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Incident Reporting Form
Vernon Emergency Medical Services
Incident Reporting Form
Section 1: Incident Details
Name:
Email:
Today's Date:
Date and Time of Incident:
Location of Incident:
Related Case Number:
Weather During Incident:
Day
Night
Sunny
Overcast
Fog
Rain
Snow
Ice
Storm
Hot
Warm
Cold
Section 2: Incident Questions
1) Did this incident happen on a call?
-- Select --
Yes
No
1a) What was the call type?
1b) Call number or address (if known):
2) Was a member injured?
-- Select --
Yes
No
2a) Name of injured member:
2b) Describe the injury:
2c) Did the member seek medical attention? If yes, where?
3) Was a patient injured?
-- Select --
Yes
No
3a) VEMS EMS Chart Number:
4) Were police notified?
-- Select --
Yes
No
4a) Which police agency was contacted?
4b) Related Case Number?
5) Was a line officer notified?
-- Select --
Yes
No
5a) Name of line officer notified:
6) Is this a personnel issue?
-- Select --
Yes
No
6a) Please describe the personnel issue:
7) Is this an Operational/Equipment Issue?
-- Select --
Yes
No
7a) Describe the equipment or operational failure:
8) Is this a Dispatching Issue?
-- Select --
Yes
No
8a) Describe the dispatching problem:
9) Did this involve another VEMS Volunteer?
-- Select --
Yes
No
9a) Name of the VEMS Volunteer involved:
10) Does this involve another agency?
-- Select --
Yes
No
10a) Name of the other agency:
10b) Names of involved members:
Section 3: Property Damage Report
Was there any damage to property?
-- Select --
Yes
No
Is the property owned by VEMS?
-- Select --
Yes
No
Not Applicable
Is the property owned by Vernon Township?
-- Select --
Yes
No
Not Applicable
Related Police Report Number:
Describe Damage and Type of Property:
Section 4: Reference Documents
Click below to view or download related documents:
Township Accident Report
Township Injury Report
VEMS Policy - Injury & Workmans Comp
Submit Report