* 1. Date and time:

free text box
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/
:

* 2. EMS Incident number:

* 3. Please select your agency from the list below

* 4. EMS provder number

* 5. Patient demographics

* 6. Is the patient?

* 7. Indication for Invasive airway management

* 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)

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

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