Air Ambulance Utilization-Incident Information

* 1. EMS Agency Reporting: (Affiliate Number/Name)

* 2. Date of Incident

Date 
/
/

* 3. Incident Location (Address)

* 4. County of Incident

* 5. Time of EMS Dispatch:

 Time
:

* 6. Time EMS Arrived on Scene

Time
:

* 7. Type of Incident

T