Active Bleeding Control -  Incident Report/ Use Case Report
Thank you for sharing your experience with using the skills of Active Bleeding Control.   

Use this form to report a situation when you used the Active Bleeding Control Training.

By providing this information you are voluntarily providing valuable information that will inform future trainings and improve understanding of the use of Active Bleeding Control techniques in your area.  This information will be used in a confidential manner by Africa Fire Mission.   You may submit this form anonymously.  

Asante kwa kushiriki uzoefu wako kwa kutumia ujuzi wa Udhibiti Amilifu wa Kuvuja Damu. Tumia fomu hii kuripoti hali ulipotumia Mafunzo ya Kudhibiti Uvujaji wa Damu. Kwa kutoa maelezo haya kwa hiari yako unatoa taarifa muhimu ambayo itafahamisha mafunzo ya siku zijazo na kuboresha uelewa wa matumizi ya mbinu za Kudhibiti Uvujaji wa Damu Inayotumika katika eneo lako. Taarifa hizi zitatumiwa kwa njia ya siri na Africa Fire Mission. Unaweza kuwasilisha fomu hii bila kujulikana.
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Date of Incident *
When did the incident take place? / Tukio hilo lilitokea lini?
MM
/
DD
/
YYYY
Time of Day *
What time of day did the incident take place? / Tukio hilo lilifanyika saa ngapi za siku?
Location *
Please be as descriptive as possible:  Road Name, City/County, Country / Tafadhali fafanua iwezekanavyo: Jina la Barabara, Jiji/Kaunti, Nchi
Cause of Injury: *
What caused the bleeding that needed controlled?  Road Traffic Accident, Work Accident, etc. / Ni nini kilisababisha kutokwa na damu kulikohitaji kudhibitiwa? Ajali ya Trafiki Barabarani, Ajali ya Kazini, n.k.
Number of Injuries *
How many people were injured in this incident? / Ni watu wangapi walijeruhiwa katika tukio hili?
Description of the incident *
Please describe in detail what happened at the incident.  Please be as complete as possible. / Tafadhali eleza kwa undani kilichotokea kwenye tukio hilo. Tafadhali kuwa kamili iwezekanavyo.
Training used: *
What parts of the training did you use?/ Ulitumia sehemu gani za mafunzo?
Required
Helpfulness of Training Skills *
What training skill was most helpful?/ Ni ujuzi gani wa mafunzo uliosaidia zaidi?
Required
What supplies did you use? *
What supplies did you use? / Ulitumia vifaa gani?
Victim Outcome *
What happened to the victim?  What was the outcome?  Did the victim survive?

Nini kilitokea kwa mwathirika? Matokeo yalikuwa nini? Je, mwathirika alinusurika?
I would like someone to contact me about my report. 

Ningependa mtu awasiliane nami kuhusu ripoti yangu.
 *
If you answered yes, that you would like someone to contact you about your report, please provide your name, phone number and email address.

Iwapo ulijibu ndiyo, kwamba ungependa mtu awasiliane nawe kuhusu ripoti yako, tafadhali toa jina lako, nambari ya simu na anwani ya barua pepe.
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