This form is for the use of all medics in the participating study sites for ORSUDS
in Multnomah, Clackamas and Clark County.

Use this form to request your coffee card or movie ticket.
Please be sure to complete all fields

Thank you for participating in this important research project.

If you have any questions or comments, please contact:
Ron Mariani at 503-805-9110, Email: marianir@ohsu.edu
or
Jamie McDaniel at 503-422-0677, Email: Jamie.McDaniel@amr.net
Incident Number *
Incident Date *
MM
/
DD
/
YYYY
Call Time *
Time
:
Medic 1: Name *
Medic 1: Incentive Choice *
Medic 2: Name *
Medic 2: Incentive Choice *
Comments / Questions / Concerns
Include any additional comments you would like to share.
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