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!

EMS Agency Reporting: (Affiliate Number/Name)

Question Title

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

Date of Incident

Question Title

* 2. Date of Incident

Date 
Incident Location (Address)

Question Title

* 3. Incident Location (Address)

County of Incident

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* 4. County of Incident

Time of EMS Dispatch:

Question Title

* 5. Time of EMS Dispatch:

 Time
Time EMS Arrived on Scene

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* 6. Time EMS Arrived on Scene

Time
Type of Incident

Question Title

* 7. Type of Incident

T