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* 1. Date and time:

free text box

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* 2. EMS Incident number:

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* 3. Please select your agency from the list below

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* 4. EMS provder number

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* 5. Patient demographics

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* 6. Is the patient?

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* 7. Indication for Invasive airway management

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* 8. Was endotracheal intubation attempted?
(for oral route, each insertion of blade is one attempt)
(for nasal route, each pass of tube past nares is one attempt)

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* 9. Please indicate the presence of any/all features suggesting a difficult airway.

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