Survivor Case Nomination Form

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Please use this form to notify the Marin County Survivors' Committee of a potential survivor case for inclusion in the annual survivors' celebration. The committee is particularly looking for cases that involve the full spectrum of EMS resources here in Marin (e.g. dispatcher CPR instructions, bystander involvement, helicopter utilization, etc.). Cases must have occurred within the past 12 months. Those cases involving survival following cardiac arrest or significant trauma are of particular interest.

Name of Person Submitting Nomination *

Phone Number of Person Submitting Nomination *

Agency of Person Submitting Nomination
*

Date of Incident *

YYYY

F# of Incident *

Brief Description of Incident *

Submit

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