Incident Report
UPPER SAUCON AMBULANCE CORPS
Reporting Employee Name
*
First Name
Middle Name
Last Name
Suffix
USAC Email
*
rev. 05/2019
Back
Next
Incident Type
*
Employee Injury
Employee Misconduct
Outside Agency Issue
Patient Care Issue
Property Damage
Vehicle Crash
Incident Date & Time
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit 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
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
Minutes
Incident Location
*
Involved Employee(s)
*
List the accused person(s), OR, in the case of a crash, list the driver, OR, in the case of an injury, list the injured employee.
Witness(es)
Back
Next
Description of Incident
*
File Upload
Browse Files
Cancel
of
Back
Next
Certification
*
I hereby certify and attest that the facts set forth in this form are true and correct to the best of my knowledge and belief. I understand that false or misleading statements may lead to disciplinary action up to and including termination and may be punishable by law.
Reporting Employee Last 4 of SSN
*
Signature
*
Form Start Date/Time
-
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
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
Minutes
Submit
Should be Empty: