MEDICAL RESPONSE INCIDENT REPORT
Date of Incident
*
/
Month
/
Day
Year
Date
Time of Incident
*
Hour Minutes
AM
PM
AM/PM Option
Location of Incident
*
Responder Name(s)
*
Participant Information
Full Name
*
First Name
Last Name
Age
*
Gender
*
Participant Phone Number
*
Emergency Contact Name
*
Relationship to Participant
*
Emergency Contact Phone
*
Medical History
Known Medical Conditions
Allergies (medications, food, environmental)
Current Medications (if known)
Chief Complaint / Nature of Incident
What happened? Please include any visible symptoms or injuries
Vital Signs - Initial Assessment
Time Taken
*
Hour Minutes
AM
PM
AM/PM Option
Blood Pressure (BP)
*
mmHg
Heart Rate (HR)
*
bpm
Respiratory Rate (RR)
*
breaths/min
Oxygen Saturation (SpO2)
*
%
Temperature
*
Degrees Fahrenheit
Level of Consciousness
*
Alert
Verbal
Pain
Unresponsive
Skin Appearance
*
Normal
Pale
Flushed
Sweaty
Cool
Warm
Support Provided
Support Provided
*
CPR
Oxygen
Bleeding Control
Cold Compress
EpiPen (Must be provided by participant or family member)
AED Applied
Reassurance Only
Description of Care Given
*
Disposition
Type of Disposition
*
Released to family or friend
Transported by EMS Agency
Refused further care
Disposition Details
Name of Family, Friend or EMS Agency (if applicable)
Time of Transfer/Release
*
Hour Minutes
AM
PM
AM/PM Option
Signatures
Responder Name
*
First Name
Last Name
Date
*
-
Month
-
Day
Year
Date
Responder Signature
*
Witness Name
*
First Name
Last Name
Date
*
-
Month
-
Day
Year
Date
Witness Signature (if applicable)
Submit
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