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NEW YORK STATE DEPARTMENT OF HEALTH
BureauofEmergencyMedicalServices
FORM DIRECTIONS
Only complete and return sections that pertain to the incident being reported. Copy additional pages as needed.
1. Please attach copies of any agency specific Incident Reports.
2. Page 2 is for general information relating to the incident only and must be completed for all reporting.
3. Section 1 must be completed if a patient is injured or dies as a result of EMS involvement.
4. Section 2 must be completed for a motor vehicle crash involving death or injury to a patient, member of the crew or other person which
requires hospitalization or care by a physician.
5. Section 3 must be completed if any member of the EMS service, civilian or other emergency responder dies or is injured requiring
hospitalization or care by a physician while on duty.
6. Section 4 must be completed for any equipment failure causing patient harm.
7. Section 5 must be completed if any member of the EMS agency is alleged to have responded or treated a patient while under the influence
of alcohol or drugs.
8. Section 6 must be completed for all incidents.
This form does not replace any incident reporting forms required by a regional council, state or federal laws
and regulation, and/or insurance policies.
This form must be completed for any injury, illness or death of an EMS provider, patient or other individual in accordance with Part 800.21(q) and
800.21(r). Each incident must be reported to the Department’s area office by telephone no later than the following business day. The completed
form must be submitted to the New York State Department of Health’s Bureau of Emergency Medical Services within 5 business days for every
incident.
EMS Service
Name
Name of EMS Service NYS EMS Agency Code
Address
Street
City State ZIP County (where incident/injury occurred)
Contact Person
Name Title
Phone ( ) – ( ) –
Business Other
Regional EMS Council (primary):
Your Agency Type (check only one)
Commercial College Fire Department Independent Not for Profit
Municipal Hospital Industrial
Incident
Location
Residence Medical Facility Commercial Facility Ambulance EASV/ALSFR Quarters
Roadway Other Event/Standby
Date of Incident Time (24 hour) Day of Week
Unit Status at Time of Incident
Available Responding On Scene En-route to Hospital At Destination Training
Type of Incident
For each patient that was injured or dies as a result of EMS involvement complete Section 1
Motor vehicle crash involving injury or death to patient, crew, civilian or other emergency personnel requiring hospitalization or care
by a physician (complete Section 2)
Any EMS Provider, Civilian or Other Emergency Provider that dies or is injured while on duty requiring hospitalization or care
by a physician (complete Section 3)
Patient equipment failure causing patient harm (complete Section 4)
Provider suspected of treating patients or responding under the influence of alcohol or drugs while on duty (complete Section 5)
Number of Persons Injured
EMS Provider
Patient Other Emergency Responder
Civilian
SECTION 1 Patient Information
Complete this section for each patient that was injured or dies as a result of EMS involvement.
Age Gender Male Female
Injury Death
Pre Event Condition
Critical Unstable Potentially Unstable Stable
Post Event Condition
Critical Unstable Potentially Unstable Stable
Pre Event Presenting Problem (check all that apply)
Airway Obstruction Pain Major Trauma
Respiratory Arrest Unconscious/Unresponsive Trauma-Blunt
Respiratory Distress Seizure Trauma-Penetrating
Cardiac Related Behavioral Disorder Soft Tissue Injury
Cardiac Arrest Substance Abuse Bleeding/Hemorrhage
Allergic Reaction Poisoning (accidental) OB/GYN
Syncope Shock Burns Environmental
Stroke/CVA Head Injury Heat
General Illness Spinal Injury Cold
Gastro-Intestinal Distress Fracture/Dislocation Hazardous Materials
Diabetic Related Amputation
Injury Occurred During (check all that apply)
Airway Management Splinting Hemorrhage control
Oxygen therapy C-spine immobilization Alleged Assault by EMS personnel
Medication error Lifting/moving Alleged Abandonment by EMS personnel
Monitor/defibrillation Patient dropped Motor vehicle crash (MVC)
Protocol error Other
Stretcher involved incident Make/Model
Stair Chair involved incident Make/Model
Reeves transfer
Body Part Affected (check all that apply)
Head Back Leg Left/ Right
Neck Abdomen Hand Left/ Right
Chest Arm Left/ Right Foot Left/ Right
Joint Left/ Right Knee Ankle Wrist Elbow Hip Shoulder
Internal Organ/System
Post Event Injury/Illness (check all that apply)
Respiratory Death Head Injury Exposure – Heat Exposure – Cold
Cardiac Fracture/Dislocation Spinal Injury Laceration Sprain/Strain
Cardiac Arrest Stroke Seizure Burn Amputation
Hemorrhage Pathogen Exposure Hazmat Trauma –Blunt Trauma –Penetrating
Other
Disposition Admission
Emergency Department Only Critical Care Admission Personal Physician
Hospital General Admission Urgent Care Other
SECTION 2 Motor Vehicle Crash
Complete this section for a motor vehicle crash involving death or injury to a patient, member of the crew or other person which requires
hospitalization or care by a physician. Also include copies of Section 1 or Section 3 as necessary.
EMS Vehicle Involved
Ambulance ALS-FR EASV Other
Ambulance Type
Type I Type II Type III Other
Amount of Damage
Minor Moderate Severe
Other Vehicle Involved
Car SUV Pickup Truck Motorcycle/ATV Commercial Vehicle
Other
Accident Type
Backing Head-On Sideswipe 90 Degree Rear End Parked
Vehicle/Pedestrian/Wildlife
General Information (check all that apply)
Intersection Lights in Use Sirens in Use Traffic Control Device Present
Mechanical Failure Airbag Deployment Entrapment
Time of Day
Daylight Night Dawn/Dusk
Weather Conditions at the Time of the Incident (check all that apply)
Clear Sunny Cloudy Foggy Rain Snow Ice
Road Conditions (check all that apply)
Dry Wet Ice Snow Other
EMS Vehicle Driver Information
EMT Number Age Gender Male Female
Hours on Duty Prior to Incident
EVOC or Agency specific driver training Restrained Unrestrained Injured
Non-EMS Certified Driver
Patient Location at Time of Incident
Restrained Unrestrained Stretcher Bench Seat Captain’s Chair
Patient Injury (must complete Section 1) No patient on board
Front Seat Passenger Information
Provider Civilian Restrained Unrestrained Unoccupied
Injury (must complete Section 3)
Compartment Occupants
EMS Provider Civilian Other Agency Restrained Unrestrained Unoccupied
Injury (must complete Section 3)
Other Vehicle Involved
Driver
Restrained Unrestrained Injury (must complete Section 3 for each injured passenger)
Passenger
Restrained Unrestrained Injury (must complete Section 3 for each injured passenger)
SECTION 3 EMS Crew Member, Civilian or Other Emergency Responder Information
Complete this section for any on-duty member of the EMS service, civilian or other emergency responder who dies or is injured requiring
hospitalization or care by a physician.
Age
Gender
Male Female
Level
CFR EMT AEMT EMT-CC EMT-P Civilian
Other Emergency Provider
Status
Paid Volunteer Driver/Helper Student
Mechanism of Injury (check all that apply)
Animal Bite Fire Assault – with weapon Assault – no weapon
Needle Stick Pathogen Electrical Injury Explosion
Struck by Vehicle Struck by Object Structural Collapse MVC
Hazardous Materials Exposure (specify )
Lifting/Bending Slip/Fall
Moving Patient Onto/Off Stretcher During Stretcher Transport
Other
Body Part Affected (check all that apply)
Head Back Leg Left Right
Neck Abdomen Hand Left Right
Chest Arm Left Right Foot Left Right
Joint Left Right Knee Ankle Wrist Elbow Hip Shoulder
Internal Organ/System
Injury/Illness Description (check all that apply)
Respiratory Death Head Injury Exposure – Heat Exposure -Cold
Cardiac Fracture/Dislocation Spinal Injury Laceration Sprain/Strain
Cardiac Arrest Stroke Seizure Burn Amputation
Hemorrhage Pathogen Exposure Hazmat Trauma –Blunt Trauma –Penetrating
Other
Equipment Description (if related to injury)
Stretcher Stair Chair Backboard Reeves
Other
Make/Model
Disposition Admission
Emergency Department Only Critical Care Admission
Personal Physician Urgent Care
Hospital General Admission
Time Lost (if known) (days)
SECTION 4 Equipment Failure
Complete this section for each equipment failure that caused patient harm. Also include Section 1 or Section 3 as necessary.
Airway Equipment (check all that apply)
Make/Model
O2 delivery device Suction CPAP
Advanced airway Nebulizer O2 tank O2 Regulator
Other
Lifting/Moving Equipment
Make/Model
Stretcher Stair Chair Reeves
Other
Splinting Equipment (check all that apply)
Make/Model
Extrication Collar Backboard Short board Frac Pack Traction Splint
Other
Other Patient Equipment (check all that apply)
Make/Model
Monitor Pulse Oximeter Glucometer IV Supplies AED
Automatic CPR Device
Other
SECTION 5 Provider treating or responding under the influence
Complete this section for member of the EMS agency is alleged to have responded or treated a patient while under the influence of
alcohol or drugs while on duty.
EMT Number
Age
Gender
Male Female
Level
CFR EMT-Basic AEMT EMT-CC EMT-P
Status
Paid Volunteer Driver/Helper Student
Substance Type
Drugs Alcohol
Allegation
Responded Patient Treatment
Details (fill out sections 1. 2 or 3 if applicable):
Injury Motor Vehicle Crash Law Enforcement Response (Agency )
Testing
Breath Blood Urine
Testing Completed by
Agency Hospital Police Department Lab/Clinic
Results
Positive Negative
%BAC Drug Type
Action Taken by Agency
Suspended Terminated Pending Removed from Service Returned to Service
SECTION 6 Narrative Section
Number of Persons Deceased
EMS Provider
________
Patient
_______
Other Emergency Responder _______
Civilian ________
