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Ambulance Accident or Personal Injury Report

This Report Must Be Filed Within 24 Hours of Incident and Within 8 Hours If Fatality Involved.

Date and Time of Accident or Injury
Date:     Time:  
Did Vehicle Driver Complete an EMSO Approved EVOC Course?

I. Service Information
Service Name:   Affiliate Number:  
Name/Title of Person Completing Report:   Email:  
Telephone: (eg. 7178675309)   Pager (optional):
Address:   City:  
State: Zip Code:  


II. Vehicle Information
STATE Vehicle Decal Number: VIN:
Vehicle Drivable after Accident: Approximate Damage Amount:

III. Motor Vehicle Accident Incident Information
Number of Each Vehicle Type Involved:
EMS: Other Emergency Service: Civilian:
Involved Collision With: (Check all that apply)


Other:
Impact Type: (Check all that apply)

 		Other:

Street Name or Route Number Where Accident Occurred:  
MCD Code Where Accident Occurred:
Nearest Intersection or Mile Marker:
Number Of Lanes: Approximate Speed Prior to Incident:
Did Incident Occur at an Intersection:
Weather: (Check all that apply)
Light Conditions: Road Surface:
Mode of Service at Time of Incident:

IV. Accident Description
Description of the Event:

V. Injury Information
The following injury reports must be completed for all EMS personnel and others injured.

n/a



VI. Police Report Information
Did Police Investigate This Incident:
Investigating Police Agency:
Address: City:
State: Zip Code:
Was a Citation Issued: Issued To:

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