UNDESIGNATED EPINEPHERINE REPORTING
(Form PH-4299 and RDA:SW15)

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* Location of Incident:

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* Authorized Entity:

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* Address (Street, City, State, Zip Code)

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* Contact Person Completing Form:

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* Telephone (Include Area Code):

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* Contact E-mail:

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* Date and Time of Incident:

Date and time

Date

Time

AM/PM