Information Report

Requesting Manager Email(Required)

Your Email(Required)

Statement of (Name in Full)(Required)

First Last

Employee #(Required)

Place of Event(Required)

Date of Event(Required)

Vehicle (if applicable)

Patient Name (if applicable)

Run Number (if applicable)

Approximate Time

REMINDER – THIS REPORT IS A LEGAL DOCUMENT AND IT NEEDS TO BE WRITTEN IN A PROFESSIONAL MANNER. THIS REPORT WILL CONTAIN DETAILED FACTS ONLY, NO PERSONAL OPINIONS. THERE WILL BE NO MEDICAL ABBREVIATIONS, SYMBOLS AND/OR AASI CODES USED. ALL STATEMENTS WILL BE PLACED IN QUOTES. IF THESE GUIDELINES ARE NOT FOLLOWED YOU WILL BE REQUESTED TO REWRITE THIS REPORT.

Description of Event(Required)

Does the Incident Personally Involve Other Employee(s)?(Required)

Yes

Have you Spoken with the Affected Employee(s)? Please Explain:(Required)

Name

This field is for validation purposes and should be left unchanged.