EMSPAC Incident Tracking Intake
This form is to be used to report incidents that occur in the day to day operations of EMS as well events that happen to members of the EMS profession.
INFORMATION IS NOT SHARED WITH OUTSIDE RESOURCES OR ORGANIZATIONS PURSUANT TO EMSPAC POLICIES.
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DATE OF INCIDENT
TIME OF INCIDENT
MEMBER ASSAULTED ON DUTY
MEMBER OF SERVICE DEATH
YOUR NAME (First Last)
YOUR CELL PHONE NUMBER
YOUR EMAIL ADDRESS
MOS INVOLVED NAME IF KNOWN (First Last)
MOS INVOLVED CELL PHONE NUMBER IF KNOWN
MOS INVOLVED AGENCY
MOS INVOLVED UNIT NUMBER
LOCATION OF INCIDENT
Please provide the borough in NYC or county and state that this incident occurred in.
DESCRIBE THE INCIDENT
WHEN, WHERE, WHO, WHAT, WHY, AND HOW WE CAN HELP
I WANT EMSPAC TO:
SELECT ALL THAT APPLY
MAKE A PRESS REPORT
HELP ME WITH A HARDSHIP CASE
HELP ME WITH TARGETING / HARASSMENT
CONTACT A LOCAL POLITICIAN
CONSULT WITH ME ON ANOTHER ISSUE
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