Occurrence Report
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SOMERSET-PULASKI COUNTY EMS
OCCURRENCE REPORTING FORM
Date Of Occurrence
Time Of Occurrence
Date
Time
Person Affected by Occurrence:
Patient
Employee
Student
Other
Other
Last Name
First Name
Middle Initial
Address
City
State
Zip Code
Social Security Number
Birth Date
Run Number
Occurrence Reported To:
To O.I.C
By
Date
Time
To Major
By
Date
Time
To Chief
By
Date
Time
To Medical Director
By
Date
Time
Witness To Occurrence
Cell Phone
Add new
Description Of Occurrence
Report Prepared By
Title
Date
Time
Actions Taken To Correct Occurrence:
By Whom
Title
Date
Time
Actions Taken To Prevent Future Occurrence:
By Whom
Title
Date
Time
Person(s) To Be Notified (use A Comma To Separate Email Addresses; Do Not Add a Space After the Comma)
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