TCB Event Medical Incident Report
To report an incident, please provide the following information
Dispatch
Event Name
Date and Time when Incident Occurred:
*
-
Month
-
Day
Year
Date Picker Icon
00
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
:
Hour
00
10
20
30
40
50
Minutes
Dispatch Reason
*
Incident Location
Time Of Arrival
00
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
:
Hour
00
10
20
30
40
50
Minutes
Time of Clear
00
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
:
Hour
00
10
20
30
40
50
Minutes
Staff
TCB Staff 1
*
First Name
Last Name
Posistion
TCB Staff 2
First Name
Last Name
Position
Additional/Observer
First Name
Last Name
ERT Tech Number (If applicable)
Patient Information
Full Name of Patient
*
First Name
Middle Name
Last Name
Date of Birth
January
February
March
April
May
June
July
August
September
October
November
December
Month
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Day
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Year
Patient Community Status
*
Guest
Employee
Vendor
Other
Sex of Patient
*
Male
Female
N/A
Phone Number
-
Area Code
Phone Number
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Chief Complaint
*
Patient Medical Details - S.A.M.P.L.E.
*
Vital Signs
Heart Rate
Blood Pressure
Respiratory Rate
SPO2
Care provided? (Assessment, vitals, apply oxygen, airway management, bleeding control...)
*
Care Provided By:
Consent
*
Implied
Expressed
Parent / Guardian
Relationship
First Name
Last Name
Phone
Parent / Guardian Address If Different Than PT Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Narrative and Transport
Narrative (Chronological or CHART)
*
Transported:
By POV
By Fire
By Amulance
By Other Responsible Adult
Refused Transport
No Transport Needed
Patient Refused Treatment
YES
NO
Date Of Refusal
-
Month
-
Day
Year
Date
00
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
:
Hour
00
10
20
30
40
50
Minutes
Patient Signature For Above Refusal
Notes/Additional Information
Other Contacts
Contact
Witness
Involved Party
Participant
Victim
Type
First Name
Last Name
Phone
Contact
Witness
Involved Party
Participant
Victim
Type
First Name
Last Name
Phone
FIRE / EMS
First Name
Last Name
Unit #
Other
First Name
Last Name
Phone
Certification of Accuracy
*
I certify that to the best of my knowledge the above information is true and correct.
Submit Report / Add Photos
Signature
Employee Submitted On
-
Month
-
Day
Year
Date
00
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
:
Hour
00
10
20
30
40
50
Minutes
What Event Manager / Promoter Notified
YES
NO
None Available
TCB Supervisor On Duty
Photos
Browse Files
Cancel
of
Submit Report Now!
Should be Empty: