Incident Report Form

Incident Report Form

Any Incident that requires reporting should be submitted through this form. APS/CPS referrals, damage to equipment/vehicles, workplace injuries, etc. Any photos should be emailed to the Deputy Director immediately.
Crew members:
Supervisor
The selected supervisor will receive a copy of the IR.
OCA (if applicable):
Address of Incident
Date of Incident:

MonthDayYear
Name of Employee Writing the IR?
What type of incident are you reporting?
🚨 LIFEPAK / Cardiac Monitor Issue

Issues involving LIFEPAK monitors are documented using a dedicated Medical Device Incident Report to ensure proper follow-up.

👉 Click HERE complete the Monitor Incident Report.

You do not need to complete this form.
Name of Patient/Family
Provide contact info for patient or family member if follow-up is required by ES Admin.
Patient/Family Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Photo Upload

Upload any photos of incident or damage for documentation
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Near Miss/Other:
What type of near miss are you reporting:

Other
Please provide details regarding incident:
Please provide any recommendations for system improvement to prevent future incidents:
APS Referral
Patient/Person being referred:
Name of Caretaker/Family if available
Reason for referral:
Name and email (if applicable) of person contacted when making referral
Please provide details regarding incident:
CPS Referral
Name of patient/person being referred:
Name of Parent(s)/Guardians(s)
Reason for referral:
Name and email (if applicable) of person contacted when making referral:
Please provide details regarding incident:
Accident/Injury
Accident type:
Please provide details regarding incident including factors that contributed to the accident:
Please provide any recommendations for system improvement to prevent future incidents:
Closer Unit Discrepancy/FMP Alert
OCA #
You location at time of dispatch?
Address (FMP Only)

Street Address

CityState / Province

Postal / Zip Code
Include details to review:
Equipment Failure/Breakage/Malfunction
List the Equipment Type
Cardiac Monitor, Ventilator, Jump Bag, Etc.
Equipment Identifier
List the identifier, ex: Monitor #, Jump bag #, etc.
Detail Issue/Incident
Be specific about what caused the breakage, or what happened during the failure. This will assist us in repair as well as keeping a history of the equipment for warranty.
Photo Upload

Upload any photos of equipment if necessary.
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Hospital IR
IR Subject

Other
Summary
Should be Empty:

Incident Report Form

Near Miss/Other:

APS Referral

CPS Referral

Accident/Injury

Closer Unit Discrepancy/FMP Alert

Equipment Failure/Breakage/Malfunction

Hospital IR