Incident Report
UPPER SAUCON AMBULANCE CORPS
Reporting Employee Name
*
First Name
Middle Name
Last Name
Suffix
USAC Email
*
rev. 05/2019
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Incident Type
*
Employee Injury
Employee Misconduct
Outside Agency Issue
Patient Care Issue
Property Damage
Vehicle Crash
Incident Date & Time
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Incident Location
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Involved Employee(s)
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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)
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Description of Incident
*
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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
*
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