Raven EMS Education Program Manual
Incident Report Form

Date:

Injured person’s name:

Location where injury occurred:

Description of incident:

Safety equipment and gear being used during the incident:

Actions taken:

Injured person was advised to seek further medical assessment and treatment:

• 9-1-1
• Emergency Room
• Walk-In Clinic or Urgent Care
• Primary Care Physician Appointment
• None
• Other:

Disposition:

Recommendations to prevent similar event from occurring in the future:

Injured person signature:
Clear

Supervisor signature:
Clear

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