Information
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Document No.
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Client / Site
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Conducted on
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Prepared by
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Location
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Personnel
Incident Summary
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Incident Location:
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Location Type:
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Operation / Department
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Incident Date:
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Date AMR Notified:
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Reported to SRM by:
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Supervisor Phone:
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Brief Summary:
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Type of Claim:
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Responsible Party:
- IV Potentially at fault/responsible
- OV Potentially at fault/responsible
- Dual IV/OV shared responsibility
- Unknown -Under investigation
- No claimant identified - hit &run
- N/A -only if no other party involved
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Number of OV's
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Total Number of OV Occupants:
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Number of OV Parties Injured:
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OV Injury Details:
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Number of OV Fatalities:
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OV Damage Level:
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OV Damage Description:
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OV Damage Pictures
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Number in AMR Vehicle (IV):
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Patient on Board?:
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Patient Name:
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Incident Number:
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Total number of IV Injuries:
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AMR Injury Detail:
- AMR driver injured
- Partner injured
- Both driver and partner injured
- Multiple AMR employees injured
- Ride-Along injured w/ crew
- Ride-Along injured only
- No AMR injuries reported
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AMR Damage Level:
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IV Damage Description:
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Other IV Occupants:
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AMR Fender ID Number
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Make / Model / Year
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AMR VIN Number:
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License Plate:
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AMR Vehicle Damage:
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Witness Information:
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Witness Information:
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Witness Information:
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Witness Information:
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Law Enforcement:
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Report Done:
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Case / Incident:
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Report:
Claimant Detail
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Primary Claimant:
- OV driver/vehicle owner
- OV driver/not vehicle owner
- OV passenger
- Other property owner (non-vehicle)
- AMR patient
- Pedestrian/bicyclist
- Other AMR passenger
- N/A - Only if no other party involved
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Claimant First Name:
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Last Name:
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Claimant Address:
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Claimant City:
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Claimant State:
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Claimant Zip Code:
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Claimant Telephone:
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Claimant Drivers License Number:
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Claimant DL State:
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Claimant DOB:
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Insurance
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Insurance Phone:
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Insurance Policy Number:
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OV Make / Model / Year:
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OV License Plate:
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DL / Registration / Insurance
Employee Detail
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AMR Driver Last, First:
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Drivers Date of Hire:
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AMR Driver SSN:
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AMR DOB:
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AMR EE Drivers License Number:
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AMR Driver Gender:
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AMR Drivers Status:
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Occupation Code:
- EMT
- Paramedic
- RN
- VST
- Supervisor / Admin
- Mechanic
- Mobile Health Technician
- Wheelchair Technician
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AMR Partner Last, First
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Attendant Date of Hire:
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AMR DOB:
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AMR Attendant Gender:
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AMR Drivers Status:
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Occupation Code:
- EMT
- Paramedic
- RN
- VST
- Supervisor / Admin
- Mechanic
- Mobile Health Technician
- Wheelchair Technician
Accident Details
Accident Details:
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Accident Type:
- IV broadsided OV
- OV broadsided IV
- IV and OV hit head-on
- IV sideswiped OV (includes mirrors)
- OV sideswiped IV (includes mirrors)
- IV rear ended OV
- OV rear ended IV
- IV was hit/damaged while parked
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Weather Conditions:
- Clear
- Rain
- Hail
- Fog
- Snow
- Other-Only is IV was in motion
- N/A - Only if IV was parked
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Road Conditions:
- Clear Pavement
- Wet
- Sleeted with hail
- Snowy and/or icy
- Muddy
- Dirt
- Gravel
- Sanded pavement
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AMR Vehicle Path:
- Driving in normal traffic direction
- Driving against normal traffic direction
- IV driving on left median
- IV driving on right shoulder
- IV slitting lanes
- Crossing freeway median divide
- Other -Only in motion
- N/A - only if IV was parked
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AMR Vehicle Status:
- Non emergent response
- Non emergent transport
- Emergent response
- Emergent transport
- Parked at scene
- In service without call
- Vehicle OOS
- Support vehicle/routine driving
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Vehicle Monitoring:
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Siren Detail:
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Warning Light Detail:
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AMR Speed Detail:
- IV traveling at posted limit
- IV traveling over posted speed limit
- IV traveling at excessive speed
- IV stopped/near stop at time of impact
- IV was parked
- Unknown-under investigation
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Intersection Detail:
- IV had green light / no stop needed
- IV made all required complete stops
- IV rolling stops involved (slowed only)
- Initial stop/no stop at open lanes
- IV made no attempt to slow or stop
- N/A only if no intersection involved
- Unknown- under investigation
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AMR Backing Detail:
- No spotter available/driver alone
- Spotter was with patient in back
- Spotter in right-cab seat
- Non-employee spotter used
- Driver did not follow spotters signals
- Spotter did not give clear signals
- Errors by both driver and spotter
- N/A only is not backing collision
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AMR Seatbelt Detail:
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Vehicle Code:
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AMR Policy:
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Preventability:
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Corrective Action:
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Action Plan-Driver:
- Remedial education/training
- Disciplinary action
- Performance improvement plan (PIP)
- Combo of discipline & education/training
- Other documented corrective action
- Not applicable
- Unknown at this time
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Date Completed-Driver:
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Action Plan-Partner:
- Remedial education/training
- Disciplinary action
- Performance improvement plan (PIP)
- Combo of discipline & education/training
- Other documented corrective action
- Not applicable
- Unknown at this time
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Date Completed-Partner:
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ETOH/Drug Test (s):
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Attachments
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Scene Photos