EMS Provider Vehicle Accident Reports 2014 - J Smith

In compliance with IAC 836, all Certified EMS Providers must submit a vehicle accident report as required by the EMS Commission when a provider vehicle is involved in a motor vehicle accident. Reports must be received within 10 working days following the accident. It is the responsibility of the organization CEO to make sure that the report is filed in a timely fashion and completed in its entirety. Failure to comply will result in enforcement of the penalties outlined in IC 16-31-3.
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1. Please provide the following information:
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2. Type of Vehicle:
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3. Please provide the time of the accident:
MM DD YYYY HH MMAM/PM
Time of Accident
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4. Please provide the location of the accident:
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5. Please provide the following information regarding the crew members:
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6. Please provide the following information regarding the driver of the ambulance:
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7. What type of emergency driver training has the driver had?
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8. When was the last time the driver took any type of emergency driver training?
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9. How many years of general driving experience does the driver have?
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10. How many years of AMBULANCE driving experience does the driver have?
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11. Was the driver restrained?
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12. Was the Driver Operating in Emergency Mode at the time of the accident?