American Ambulance Service, Inc

One American Way, Norwich, Ct 06360

Information Report

Reminder: This report is a legal document and it needs to be written in a professional manner. This report will contain detailed facts only, no personal opinions. There will be no medical abbreviations, symbols and/or American Ambulance Service codes used. All statements will be placed in quotes. If these guidelines are not followed you will be requested to rewrite this report.

This report is to be submitted within 24 hours of the initial request unless otherwise authorized by the requesting manager.

Requested By:
Other:
Statement Of:
Employee Number:
Email Address: A value is required.Invalid format.
Place of Event:
Date of Event:
Vehicle (if Applicable):
Patient Name (if Applicable):
Run Number:
Approximate Time
Description of Event:
Does this incident personally involve other employees?



Have you spoken with the affected employee(s)? Please explain: