MEDICAL RESPONSE INCIDENT REPORT

MEDICAL RESPONSE INCIDENT REPORT
Date of Incident*

MonthDayYear
Date
Time of Incident*

Hour Minutes

AM/PM Option
Location of Incident*
Responder Name(s)*
Participant Information
Full Name*

First NameLast 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 Option
Blood Pressure (BP)*
mmHg
Heart Rate (HR)*
bpm
Respiratory Rate (RR)*
breaths/min
Oxygen Saturation (SpO2)*
%
Temperature*
Degrees Fahrenheit
Level of Consciousness*

AlertVerbalPainUnresponsive
Skin Appearance*

NormalPaleFlushedSweatyCoolWarm
Support Provided
Support Provided*

CPROxygenBleeding ControlCold CompressEpiPen (Must be provided by participant or family member)AED AppliedReassurance Only
Description of Care Given*
Disposition
Type of Disposition*

Released to family or friendTransported by EMS AgencyRefused further care
Disposition Details
Name of Family, Friend or EMS Agency (if applicable)
Time of Transfer/Release*

Hour Minutes

AM/PM Option
Signatures
Responder Name*

First NameLast Name
Date*

MonthDayYear
Date
Responder Signature*

Clear
Witness Name*

First NameLast Name
Date*

MonthDayYear
Date
Witness Signature (if applicable)

Clear
Should be Empty:

Participant Information