HTML Preview Emergency Response Incident Report page number 1.
EMERGENCY RESPONSE TEAM INCIDENT REPORT
Location (Facility & Address): Primary Responder:
Department/Division:
Exact Location Within the Facility: Other Responders:
Date of Incident: Time:
Patient’s Name: County Employee? Yes No
If County Employee, Department/Division:
Title/Classification: Work Phone number:
DESCRIPTION
Describe clearly how the patient was discovered, primary symptoms and/or complaint, and what emergency actions
were taken: (Attach additional sheet, if needed)
ACTIONS REQUIRED
Treatment Declined First Aid Only Treatment by EMS Required
AED Used Other Describe:
Transported to Hospital If known, which hospital?
ANALYSIS
Please provide your evaluation of the ways and methods with which the situation was handled and suggestions for
improvement in the future: (Attach additional sheet, if needed)
Printed Name Signature: Date:
February 7, 2002