Air Ambulance Utilization-Incident Information

We are asking the highest level of agency at the scene to provide the information below on the premise that you will have the most information, and are most likely to complete the survey.  Realizing that you may not have requested the air ambulance, EMS agencies are most likely to have patient information and be able to appropriately answer the questions on whether an air ambulance was requested and utilized appropriately.  Thanks you for your assistance!

* 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