Version 7.9.14 lj

FILL TO LINE 8 and Fax to designated responsible function unit
or save and send to Grand Junction Dispatch center, FO or RD
PRIOR TO STARTING PROJECT

Project Description/Location

PROJECT NAME & TYPE: Click here to enter text.

START DATE: Click here to enter a date.

FIELD, A/G CONTACT: Click here to enter text. PHONE NUMBER: Click here to enter text.

RADIO FREQUENCY: Click here to enter text.

PROJECT LOCATION DESCRIPTION: (ex: North of Rifle on top of the Flat Tops, along the Buford/New Castle Road)
Click here to enter text.

Latitude: Click here to enter text. ° Click here to enter text. ‘

Longitude: Click here to enter text. ° Click here to enter text. ‘

6. TRAVEL ROUTE TO PROJECT AREA: (From closest main route , driving distance from paved road)
Click here to enter text.

7.	NEAREST LAT/LONG HELISPOT

Latitude: Click here to enter text. ° Click here to enter text. ‘

Longitude: Click here to enter text. ° Click here to enter text. ‘

8. SPECIAL INFORMATION/ FLIGHT HAZARDS: (visual… power lines, towers, etc…add Lat x Long)

Click here to enter text.

Medical Incident Report

Use items one through nine to communicate situation to communications/dispatch.

CONTACT COMMUNICATIONS/DISPATCH

Ex: “Communications, Div. Alpha. Stand-by for Priority Medical Incident Report.” (If life threatening request designated frequency be cleared for emergency traffic.)

INCIDENT STATUS: Provide incident summary and command structure

Nature of Injury/Illness	Click here to enter text.	Describe the injury (Ex: Broken leg with bleeding)
Incident Name:	Click here to enter text.	Geographic Name + “Medical” (Ex: Trout Meadow Medical)
Incident Commander:	Click here to enter text.	Name of IC
Patient Care:	Click here to enter text.	Name of Care Provider (Ex: EMT Smith)

INITIAL PATIENT ASSESSMENT: Complete this section for each patient. This is only a brief, initial assessment. Provide additional patient info after completing this 9 Line Report. See page 100 for detailed Patient Assessment.

Number of Patients: Click here to enter text.	Male ☐ Female ☐	Age: Click here to enter text.	Weight: Click here to enter text.

Conscious?	☐Yes	☐ No = MEDEVAC!
Breathing?	☐Yes	☐ No = MEDEVAC!
Mechanism of Injury: What caused the injury?	Click here to enter text.
Lat/Long (Datum WGS 84) Ex: N 40°42.45’ x W 123° 03.24’	Lat Click here to enter text. Long Click here to enter text.

SEVERITY OF EMERGENCY, TRANSPORT PRIORITY

SEVERITY	TRANSPORT PRIORITY
☐ URGENT – RED Life threatening injury or illness. Ex: Unconscious, difficulty breathing, bleeding severely, 2º-3º burns more than 4 palm sizes, heat stroke, disoriented.	Ambulance or MEDEVAC helicopter. Evacuation need is IMMEDIATE.
☐ PRIORITY-YELLOW Serious injury or illness. Ex: Significant trauma, not able to walk, 2º-3º burns not more than 1-2 palm sizes	Ambulance or consider air transport if at remote location. Evacuation may be DELAYED.
☐ ROUTINE-GREEN Not a life threatening injury or illness. Ex: Sprains, strains, minor heat-related illness	Non-Emergency. Evacuation considered Routine of Convenience.

TRANSPORT PLAN:

Air Transport:	(Agency Aircraft Preferred)
☐Helispot	☐Short-haul/Hoist	☐Life Flight	☐Other
Ground Transport:
☐Self-Extract	☐Carry -Out	☐Ambulance	☐Other

ADDITIONAL RESOURCE/EQUIPMENT NEEDS:

☐ Paramedic/EMT(s)	☐Crew(s)	☐ SKED/Backboard/C-Collar
☐Burn Sheet(s)	☐Oxygen	☐Trauma Bag
☐Medications	☐IV/Fluid(s)	☐ Cardiac Monitor/AED
☐ Other (e.g. splints, rope rescue, wheeled litter	Click here to enter text.

COMMUNICATIONS:

Function	Channel Name/Number	Receive (Rx)	Tone/NAC*	Transmit (Tx)	Tone/NAC*
Ex: Command	Forest Rpt, Ch. 2	168.3250	110.9	171.4325	110.9
COMMAND	Click here to enter text.	Click here to enter text.	Click here to enter text.	Click here to enter text.	Click here to enter text.
AIR-TO-GRND	Click here to enter text.	Click here to enter text.	Click here to enter text.	Click here to enter text.	Click here to enter text.
TACTICAL	Click here to enter text.	Click here to enter text.	Click here to enter text.	Click here to enter text.	Click here to enter text.

*(NAC for digital radio system)

EVACUATION LOCATION:

Lat/Long (Datum WGS 84) Ex: N 40°42.45’ x W 123° 03.24’	Click here to enter text.
Patient’s ETA to Evacuation Location:	Click here to enter text.
Helispot/Extraction Size and Hazards	Click here to enter text.

CONTINGENCY:

Click here to enter text.

REMEMBER:

Confirm ETAs of resources ordered.

Act according to your level of training.

Be alert. Keep Calm. Think Clearly. Act Decisively.