2601 E Chapman Ave, Orange,

CA 92869, United States

Medical Incident Report

Use items one through nine to communicate situation to communications/dispatch.
1. CONTACT COMMUNICATIONS/DISPATCH
Ex: “Communications, Div. Alpha. Stand-by for Priority Medical Incident Report.” (If life threatening request designated
frequency be cleared for emergency traffic.)

2. INCIDENT STATUS: Provide incident summary and command structure

Nature of Injury/Illness Deep lacerations on leg and arm Describe the injury (Ex: Broken
with possible infection leg with bleeding)
Patient Name Armstrong Terry Lives in Texas
Patient Age 44

Incident Commander: Mirabel Weber Name of IC

Patient Care: EMT Smith Name of Care Provider

3. INITIAL PATIENT ASSESSMENT: Complete this section for each patient. This is only a brief, initial assessment.
Provide additional patient info after completing this 9 Line Report. See page 100 for detailed Patient Assessment.
Number of Patients: Male/Female Age: Weight:
o YES NO = MEDEVAC!
Conscious?
o YES NO = MEDEVAC!
Breathing?

Mechanism of Injury: Mr. Armstrong Terry was the front seat passenger wearing his seatbelt in a vehicle being
What caused the injury? driven by a colleague which was in a collision with a vehicle that pulled out of a side road;
their vehicle span through 540o 5 . He explained that he was nodding off when this happened
and he was extremely shocked and anxious.

Lat./Long. (Datum WGS84)

Ex: N 40º 42.45’x W 123º 03.24’ 33°47'59.6"N 118°09'22.0"W

4. SEVERITY OF EMERGENCY, TRANSPORT PRIORITY

SEVERITY TRANSPORT PRIORITY

oURGENT-RED Life threatening injury or illness. Ex: Ambulance or MEDEVAC helicopter.

Unconscious, difficulty breathing, bleeding severely, 2º-3º Evacuation need is IMMEDIATE.
burns more than 4 palm sizes, heat stroke, disoriented.
o PRIORITY-YELLOW Serious injury or illness. Ex:
Significant trauma, not able to walk, 2º-3º burns not more than Ambulance or consider air transport if at
1-2 palm sizes remote location. Evacuation may be
DELAYED.
ALTH
o ROUTINE-GREEN HE
Non-Emergency. Evacuation
C
K P of Convenience.
Not a life threatening injury or illness. Ex: Sprains, strains,
minor heat-related illness considered Routine

Sign:
5. TRANSPORT PLAN:
Air Transport: (Agency Aircraft Preferred)
o Helispot
o Short-haul/Hoist oLife Flight o Other
Ground Transport:
o Self-Extract
o Carry-Out o Ambulance o Other

6. ADDITIONAL RESOURCE/EQUIPMENT NEEDS:

oParamedic/EMT(s) o Crew(s) o SKED/Backboard/C-Collar

oBurn Sheet(s) o Oxygen o Trauma Bag
oMedication(s) o IV/Fluid(s) o Cardiac Monitor/AED
oOther (e.g., splints, rope rescue, wheeled litter)

7. COMMUNICATIONS:
Function Channel Name/Number Receive (Rx) Tone/ NAC* Transmit (Tx) Tone/
NAC*

COMMAND Forest Rpt, Ch. 2 168.3250 110.9 171.4325 110.9

AIR-TO-GRND

TACTICAL

8. EVACUATION LOCATION:

Lat./Long. (Datum WGS84)

33°47'59.6"N 118°09'22.0"W

Patient’s ETA to Evacuation Location:

Helispot/Extraction Size and Hazards

ALTH
C HE
KP
9. CONTINGENCY:
Sign:
Considerations: If primary options fail, what actions can be implemented in conjunction with primary evacuation
method? Be thinking ahead…