Injury / Illness Report

• Enter Incident Date [yyyymmdd]

• Patient Last Name

• Patient First Name

Primary Patient

• Last Name

• First Name

• Gender

  Male

  Female

  Perfer not to answer

• Date of Birth

  Date

• Phone Number

• Address
  Address

• Social Security Number

• Patient Category

  Select Dynamic Aviation Supervised Contractor Leidos Other Contractor Visitor Other

  • Dynamic Aviation
  • Supervised Contractor
  • Leidos
  • Other Contractor
  • Visitor
  • Other

• Employee Number

• Hire Date

  Date

• Contract Agency

• Company Name

• Type of work being performed

• Dynamic Aviation Point of Contact

• Dynamic Aviation Point of Contact

• Tour or visitor group name

• Explain

• Additional Patients

  No

  Yes

  MCI

• NOTE: Separate Incident Reports are required for each patient. Fill in as much information as possible below to assist with associating multiple patients to one incident.

Additional Patients

• Last Name

• First Name

• Male

  Female

  Perfer not to answer

• Date of Birth

  Date

• Phone Number

• Address
  Address

• Employee Number

• Social Security Number

• Mass Casualty Incident is any incident that overwhelms the current resources available and is criteria for an automatic 911 activation.

• Mental Status

  Alert & Oriented

  Verbal Stimuli

  Painful Stimuli

  Unresponsive

• AEIOU-TIPS
  A: Alcohol or Acidosis
  E: Endocrine, Epilepsy, Electrolytes, or Encephalopathy
  I: Infection
  O: Opiates or overdose
  U: Uremia or Underdose
  T: Trauma
  I: Insulin
  P: Poisoning, Psychosis, or Pharmacology
  S: Stroke, Seizure, Syncope

• Possible cause of altered mental status

• 911 Activation Required!
  
  AEIOU-TIPS
  A: Alcohol or Acidosis
  E: Endocrine, Epilepsy, Electrolytes, or Encephalopathy
  I: Infection
  O: Opiates or overdose
  U: Uremia or Underdose
  T: Trauma
  I: Insulin
  P: Poisoning, Psychosis, or Pharmacology
  S: Stroke, Seizure, Syncope

• Possible cause of altered mental status

• 911 Activation Required!
  
  AEIOU-TIPS
  A: Alcohol or Acidosis
  E: Endocrine, Epilepsy, Electrolytes, or Encephalopathy
  I: Infection
  O: Opiates or overdose
  U: Uremia or Underdose
  T: Trauma
  I: Insulin
  P: Poisoning, Psychosis, or Pharmacology
  S: Stroke, Seizure, Syncope

• Possible cause of altered mental status

• Airway

  Patent

  Obstruction

  Compromized

  Other

• Consider 911 activation.

• Breathing

  Normal

  Labored

  Noisy

  Difficuly

  Apnea

• Consider 911 activation.

• Circulation

  Normal

  Hemorrhage

  Poor Perfusion

  Pulseless

• Consider 911 activation.

Chief Complaint

• Chief Complaint category

  Select Trauma Medical Other

  • Trauma
  • Medical
  • Other

• Select Assault Back Pain Burns Electrical Shock Eye Injury Falls Hemorrhage Laceration Unknown / Other

  • Assault
  • Back Pain
  • Burns
  • Electrical Shock
  • Eye Injury
  • Falls
  • Hemorrhage
  • Laceration
  • Unknown / Other

• Select Abdominal Pain Allergic Reaction Altered Mental Status Cardiac / Chest Pain Choking Difficulty Breathing General Illness Headache Heat/Cold Exposure Mental Illness OB Related Pain Poisioning Seizure Stroke / CVA Syncope Unknown / Other

  • Abdominal Pain
  • Allergic Reaction
  • Altered Mental Status
  • Cardiac / Chest Pain
  • Choking
  • Difficulty Breathing
  • General Illness
  • Headache
  • Heat/Cold Exposure
  • Mental Illness
  • OB Related
  • Pain
  • Poisioning
  • Seizure
  • Stroke / CVA
  • Syncope
  • Unknown / Other

• Select Wellness Check Entrapment Other

  • Wellness Check
  • Entrapment
  • Other

Vital Signs

• Vital Signs taken?

  Yes

  No

  N/A

• Time taken

  Date

• Pulse Rate

• Blood Pressure

• Respiratory Rate / Quality

• Lung Sounds

• Level Of Consciousness (person, place, time, event)

  AOx4

  AOx3

  AOx2

  AOx1

  Unresponsive

• 911 activation required!

• Pupils

  Select PEARL Dilated pupil(s) Constricted pupil(s) Abnormal reaction Abnormal movement

  • PEARL
  • Dilated pupil(s)
  • Constricted pupil(s)
  • Abnormal reaction
  • Abnormal movement

• 911 activation required!

• Description of eye assessment

• Skin

  Warm, Pink, Dry

  Cool, Pale, Clammy

  Other

• Temperature (note method)

• Oxygen Saturation (note condition)

• Room Air

  Cannula

  NRB

  BVM

• Oxygen Flow Rate

  4 L/min

  15 L/min

  Other

• Custom Flow Rate

• Blood Glucose Reading

Vital Signs - Additional Readings

• Time Taken

  Date

• Pulse Rate

• Blood Pressure

• Respiratory Rate / Quality

• Lung Sounds

• Level Of Consciousness (person, place, time, event)

  AOx4

  AOx3

  AOx2

  AOx1

  Unresponsive

• 911 activation required!

• Pupils

  Select PEARL Dilated pupil(s) Constricted pupil(s) Abnormal reaction Abnormal movement

  • PEARL
  • Dilated pupil(s)
  • Constricted pupil(s)
  • Abnormal reaction
  • Abnormal movement

• 911 activation required!

• Description of eye assessment

• Skin

  Warm, Pink, Dry

  Cool, Pale, Clammy

  Other

• Temperature (note method)

• Oxygen Saturation (note condition)

• Room Air

  Cannula

  NRB

  BVM

• Oxygen Flow Rate

  4 L/min

  15 L/min

  Other

• Custom Flow Rate

• Blood Glucose Reading

SAMPLE History

• Signs and Symptoms

• Allergies

• Medications

• Past Medical History (pertinent to this event)

• Last Oral Intake (solid or liquid, note time)

• Events leading to the injury or illness

OPQRST-ASPN History of Event

• Onset (what was patient doing when it started)

• Provocation or palliation (does anything make it better or worse)

• Quality (Patient's description of pain)

• Region or Radiation (where is it and does it travel)

• Severity (Pain Scale)

• Time (how long has it been occurring and how long since its changed, better or worse)

• Associated Symptoms

• Pertinent Negatives

Glasgow Coma Scale

• Any signs of altered mental status?

  No

  Yes

  N/A

• IMPORTANT: Any individual score of 1, 2, or 3 or any total score less than 12 requires 911 activation.

• Eye opening

  4 - Spontaneous

  3 - Verbal Stimulation

  2 - Painful Stimulation

  1 - None

• Verbal

  5 - Oriented/Appropriate

  4 - Confused

  3 - Inapporiate Words

  2 - Non-specific sounds

  1 - none

• Motor

  Select 6 - Obeys commands 5 - Localization of Pain 4 - Withdrawl (pain) 3 - Flexor posturing (pain) 2 - Extensor posturing (pain) 1 - none

  • 6 - Obeys commands
  • 5 - Localization of Pain
  • 4 - Withdrawl (pain)
  • 3 - Flexor posturing (pain)
  • 2 - Extensor posturing (pain)
  • 1 - none

• GCS Score

Cincinnati Prehospital Stroke Scale (FAST)

• Stroke symptoms suspected

  No

  Yes

  N/A

• IMPORTANT: Any abnormal indications require immediate 911 activation. Relay FAST information to 911 operator

• F - Face; Have patient smile or show teeth

  Normal

  Abnormal

  n/a

• A - Arm; Have patient close eyes, extend arms, palms up

  Normal

  Abnormal

  n/a

• S - Speech; Have patient repeat "you can't teach an old dog new tricks"

  Normal

  Abnormal

  n/a

• T - Time; last seen normal

  Date

• T - Time; onset of symptoms

  Date

Burn Assessment

• Do injuries include burns

  No

  Yes

  N/A

• Type of Burn

  Thermal

  Dry Chemical

  Liquid chemical

  Electrical

• Source of burn (item or chemical)

• IMPORTANT: If a chemical was involved, a Safety Data Sheet (SDS) must be printed and given to outside care providers if outside treatment is expected.

• Describe location of burn(s)

• Total BSA afftected

• BSA diagram

  

• IMPORTANT: Answering YES to any of the following questions indicates consideration of Burn Unit Referral. Activate 911 and relay pertinent information.

• Partial or full thickness burns greater than 10% total body surface area. (for patients under 10 or over 50 years old)

  No

  Yes

  N/A

• Partial thickness burns and full thickness burns greater than 20% BSA (between 10 - 50 years of age)

  No

  Yes

  N/A

• Partial thickness and full thickness burns involving face, eyes, ears, hands, feet, genitalia or perineum or those that involve skin overlying major joints

  No

  Yes

  N/A

• Full thickness burns greater than 5% BSA in any age group

  No

  Yes

  N/A

• Electrical burns, including lightning injuries

  No

  Yes

  N/A

• Significant chemical burns

  No

  Yes

  N/A

• Inhalation injuries

  No

  Yes

  N/A

• Burn injury in patients with pre-existing illness that could complicate management, prolongs recovery, or affects mortality

  No

  Yes

  N/A

• Level of care provided (select all that apply)

  Select None Assessment First Aid Emergency Care Refusal Other

  • None
  • Assessment
  • First Aid
  • Emergency Care
  • Refusal
  • Other

• NOTE: Must complete patient refusal section.

• Wound Care provided

  No

  Yes

  N/A

• Were protocols performed

  No

  Yes

  N/A

• Select Glucometry Tourniquet Aspirin EpiPen, Assisted MDI, assisted

  • Glucometry
  • Tourniquet
  • Aspirin
  • EpiPen, Assisted
  • MDI, assisted

• Perform Rapid Glucose Determination

  < 60 mg/dL

  61 - 139 mg/dL

  > 140 mg/dL

• 911 Activation Required!

• Provide must meet following qualifications:
  1) EMT-B or higher
  2) DART Annual Protocol Review
  
  Patient must meet following criteria:
  1) Patent airway
  2) Able to swallow
  3) Altered mental status AND known history of diabetes controlled by medication
  
  Administration:
  Place 15 grams between cheek and gum (with or without tongue depressor)

• 911 Activation Required!

• Application of tourniquet is an automatic qualifier for 911 activation. Notify emergency dispatcher that a tourniquet has been applied and the time and body location.

• Time tourniquet applied

  Date

• Body location tourniquet applied

• Aspirin considered due to presentation of chest pain?

  Yes

  No

  N/A

• Patient over the age of 16

  Yes

  No

  N/A

• Patient states no known allergy to acetylsalicylic acid (or Aspirin)?

  Yes

  No

  N/A

• Patient states no history of gastrointestinal bleeding, no signs of active bleeding within past 24 hours, or signs of bleeding within past 14 days

  Yes

  No

  N/A

• No visible indications of stroke (perform Cincinnati Pre-hospital Stroke Scale)

  Yes

  No

  N/A

• Acute chest pain present or prolonged (over 10 minutes)?

  Yes

  No

  N/A

• Initial vital signs taken (pre-administration)?

  Yes

  No

  N/A

• Directed by:

  Nurse Triage

  911 Operator

  On-site provider

• Provider Name / Agency

• Provider level

  EMT

  AEMT

  Medic

  Paramedic

• Give Aspirin via 4 chewable tablets (81mg each) PO with water IF:
  1) ALL above responses are YES
  2) Administration directed by Nurse Triage, 911 Operator, or appropriately qualified provider on-scene
  3) Responder is appropriately trained and qualified to provide medication
  
  Monitor patient and retake vital signs in 2 minutes.

Post administration vital signs

• Select date

  Date

• Pulse Rate / Quality

• Blood Pressure

• Explain non-chest pain use of Aspirin

• Transportation

  None

  Self

  Company

  Ambulance

  Other

• Reason for non-transport

  Not Required

  Refusal

  Other

• Note: Must complete patient refusal section.

• 1) I understand that I may have an injury or illness that poses an additional risk when driving;
  
  2) I understand that it is not the recommendation of Dynamic Aviation Group, Inc. nor the Dynamic Aviation Response Team to operate a vehicle with injuries or illnesses including but not limited to:
  a) Eye injuries or vision problems,
  b) Altered mental status of loss of consciousness,
  c) Head injuries,
  d) Dizziness or lightheadedness,
  e) Possibility of heart attack, chest pain, stroke and/or seizures,
  f) Hand injuries, especially those creating additional difficulty while driving,
  g) Foot injuries, especially those creating additional difficulty while driving,
  h) Uncontrolled hemorrhages,
  I) Major hemorrhages, even if currently controlled,
  j) Painful injuries and/or illnesses;
  
  3) I accept that I am choosing to operate a personal vehicle and understand that I have been acknowledged of the potential risk of doing so.

• Patient Signature

  Sign

• Ambulance Unit Number

• List other transportation method

• Destination

  None

  Clinic

  Hospital

  Other

• Select Clinic

  MedExpress

  Occupational Health

  Other

• MedExpress Urgent Care
  1840 East Market Street
  Harrisonburg, VA 22802
  (540) 432-3080

• Sentara Occupational Health Specialists
  1790 East Market Street, Suite 64B
  Harrisonburg, VA 22801
  (540) 564-5700

• Facility Name

• Facility Address
  Address

• Select Hospital

  Sentara RMH

  Augusta Medical

  Other

• Sentara Rockingham Memorial Hospital
  2010 Health Campus Drive
  Harrisonburg, VA 22801
  (540) 689-1000

• Augusta Health
  78 Medical Center Drive
  Fishersville, VA 22939
  (540) 332-4000

• Facility Name

• Facility Address
  Address

• Facility Type

• Facility Name

• Facility Address
  Address

• Patient refusal of any part of assessment, treatment, or transportation?

  No

  Yes

  N/A

Provider

• Refused:

  Select Assessment Treatment Transportation

  • Assessment
  • Treatment
  • Transportation

• Provider:
  1) Patient must have sufficient information about his/her medical condition,
  2) Patient must understand the risks and benefits of available options, including the option not to act,
  3) Patient must have the ability to use information to make a decision in keeping with his/her personal values,
  4) Patient must be able to communicate his/her choices,
  5) Patient must have freedom of will to act without undue influence from other parties, including family, friends, or and/or co-workers,
  6) Patient must meet the patient refusal criteria listed below.

• Patient Refusal Criteria (Virginia)

  Select Over 18 years old AOx4 No head injury affecting mental status No Altered LOC

  • Over 18 years old
  • AOx4
  • No head injury affecting mental status
  • No Altered LOC

• Select Married Pregnant Mother Emancipated Other

  • Married
  • Pregnant
  • Mother
  • Emancipated
  • Other

• Explain reasoning for underage refusal:

• Provider Signature

  Sign

• Select date

  Date

Patient

• 1) I understand what has been explained to me about my (or the patient's) current medical problem(s) and/or injuries;
  
  2) I realize that refusing treatment at this time or refusing transportation to an outside medical facility for further evaluation and treatment could make my (or the patient's) condition worsen and/or cause additional problems to develop including death or permanent disability;
  
  3) I release all of those currently involved in my care and Dynamic Aviation Group, Inc. from any liability (legal action) regarding the eventual outcome of the medical problem or injury for which I (or the patient) am refusing treatment and/or transportation to an outside medical facility;
  
  4) I understand that I (or the patient) have the right to request additional care at a later time for the present medical condition or injury.

• Patient Signature

  Sign

• Patient

  Parent / Legal Guardian

  Other

• Explain

• Select date

  Date

• Is this incident work related?

  Yes

  No

  Unsure

• Specific activity being performed

• Equipment

  Yes

  No

  N/A

• Materials

  Yes

  No

  N/A

• Chemicals

  Yes

  No

  N/A

• What PPE was used?

  Select Safety glasses Splash goggles Face shield Nitrile gloves Chemical gloves Cut-resistant gloves Particulate mask Half-face respirator Hearing protection Footwear

  • Safety glasses
  • Splash goggles
  • Face shield
  • Nitrile gloves
  • Chemical gloves
  • Cut-resistant gloves
  • Particulate mask
  • Half-face respirator
  • Hearing protection
  • Footwear

• Did patient bleed or otherwise lose body fluids?

  No

  Yes

  N/A

• Did all care providers and assistants wear appropriate personal protective equipment?

  Yes

  No

  N/A

• Did any provider or other personnel come in contact with blood or other potentially infections material?

  No

  Yes

  N/A

• The Environmental Compliance and Safety Department must be notified immediately of any potential exposures.

• Enter the names of each person who may have been in contact with potential infectious materials

• Did blood or other potentially infectious materials come in contact with surfaces, furniture, and/or equipment?

  No

  Yes

  N/A

• Did appropriately trained personnel cleanse or properly dispose of surfaces and/or items?

  Yes

  No

  N/A

• Were contaminated sharps, such as knives, razor blades, etc., placed in appropriately designated biohazard sharps containers?

  Yes

  No

  N/A

Personnel

• Select Chief 01: Weisgerber, J.; EMT Captain 03: Estep, K.; EMT Captain 08: Grey, R. PM 05: Hester, C. PM 06: Price, M. PM 07; Thompson, O. PM 09: Flavell, D. PM 10: Gannon, J. PM 11: Naftel, L. PM 12: Robinson, B. PM 13: Robbie, J.

  • Chief 01: Weisgerber, J.; EMT
  • Captain 03: Estep, K.; EMT
  • Captain 08: Grey, R.
  • PM 05: Hester, C.
  • PM 06: Price, M.
  • PM 07; Thompson, O.
  • PM 09: Flavell, D.
  • PM 10: Gannon, J.
  • PM 11: Naftel, L.
  • PM 12: Robinson, B.
  • PM 13: Robbie, J.

Incident Location

• Property Ownership

  Main Airport Facility

  Other Company Owned

  Non-Company Owned

• Select Building 1 (Leidos) Building 2 (3-Bay) Building 3 (Hangars ABC) Building 4 (Front Office) AAB Hangars D/E

  • Building 1 (Leidos)
  • Building 2 (3-Bay)
  • Building 3 (Hangars ABC)
  • Building 4 (Front Office)
  • AAB
  • Hangars D/E

• Select Buildings 5/6 Equipment Shed Building 7 Logistics Center Red Brick House Crew House

  • Buildings 5/6
  • Equipment Shed
  • Building 7
  • Logistics Center
  • Red Brick House
  • Crew House
• Add location
  Address

Response Information

• Delayed Response

  No

  Yes

  N/A

• Select Dispatch Response Scene Transport Return

  • Dispatch
  • Response
  • Scene
  • Transport
  • Return

• Dispatch delays

  Select Caller Uncooperative High Call Volume Location determination No Units Available Safety Conditions Other

  • Caller Uncooperative
  • High Call Volume
  • Location determination
  • No Units Available
  • Safety Conditions
  • Other

• Response delays

  Select Crowd Directions Distance Diversion Hazmat Safety Delay Weather Other

  • Crowd
  • Directions
  • Distance
  • Diversion
  • Hazmat
  • Safety Delay
  • Weather
  • Other

• Scene delays

  Select Crowd Directions Location Hazmat Safety Delay Weather Other

  • Crowd
  • Directions
  • Location
  • Hazmat
  • Safety Delay
  • Weather
  • Other

• Transportation delays

  Select Delayed Arrival Access to Pt. Loading Pt. Delayed departure Other

  • Delayed Arrival
  • Access to Pt.
  • Loading Pt.
  • Delayed departure
  • Other

• Return delays

  Select Clean-up Decontamination Documentation Equipment Supplies Other

  • Clean-up
  • Decontamination
  • Documentation
  • Equipment
  • Supplies
  • Other

Other Resources

• 911 Activated?

  No

  Yes

  N/A

• Select Rescue 15 Company 15 Other

  • Rescue 15
  • Company 15
  • Other

• List other agencies

• Incident Narrative (chronological format)

• Patient Signature

  Sign

• Supervisor's Signature (highly encouraged)

  Sign

• Responder Signature

  Sign

• Officer's Signature

  Sign