F.C.B.C.A Emergency Incident Report
This form is only use by F.C.B.C.A.
Name of individual *
Your answer
Age of individual *
Your answer
Name of child's parent (or type "N/A") *
Your answer
Name of adult in charge at the time of incident *
Your answer
Date of incident *
MM
/
DD
/
YYYY
Time
:
Did the individual pass out? *
Is the individual alert and oriented? *
Required
Was the individual bleeding? *
What happened? What caused the injury? *
Your answer
How does the individual say he/she feels?
"I feel fine." "I can't breathe." "I don't remember what happened."
Your answer
How bad does it hurt?
Doesn't hurt at all!
Worst pain I've ever felt
Describe the injury *
Your answer
What medical intervention was done? *
Stopped the bleeding? Stabilized the injury? CPR?
Your answer
Was the individual's parent(s) contacted? *
Required
Was an ambulance offered?
"Would you like me to call 911?"
What did parents request? *
Required
If transported by ambulance, which agency? *
Ex: Gwinnett County Fire Dept. Med 19. **Remember to specify unit number. Or write "N/A"**
Your answer
Was police involved? If so, please provide police case number in "Other"
What was the ambulance case number? Write "N/A" if not applicable. *
For Gwinnett Fire, it will be "GF_____"
Your answer
If by ambulance, which hospital are they being taken to? *
Gwinnett Medical Center (GMC). Children's Hospital of Atlanta (CHOA). Or "N/A."
Required
Witness(s) to the incident *
Your answer
Name of person filling out this form *
Your answer
Email Address *
Your answer
I have answered all questions honestly and to the best of my knowledge and training. *
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