Injury Incident Report (Emergency/EMS Activation)

Report Type: Injury Incident Report (Emergency/EMS Activation)

Event Classification: [Injury with EMS activation / Injury without EMS activation / Near miss / Other]

Report Status: [Draft / Final / Amended]

Facility/Site: [Facility or site name]

Location: [Exact on-site location]

Report Date/Time: [Date and time with timezone]

Author: [Name, role/title, contact]

Incident ID: [ID / Pending]

EMS Incident Number: [Number / Unknown]

Persons Involved

Injured Person: [Full name], [DOB], [age], [sex], [category: patient / visitor / staff / student / other], [primary language if known]

Guardian/Responsible Party: [Name, relationship, phone, reachable during incident: Yes / No] (Include only for minors or individuals with a known surrogate; omit entirely for competent adults without surrogates.)

Event Summary

[Mechanism/event type, exact location and environmental conditions, date/time, activity at time of incident, chief concern prompting response, and objective reason EMS was activated. Include equipment/objects involved and whether removed from service if applicable.] (Use neutral, source-attributed language; avoid diagnostic conclusions.)

Timeline

(Use consistent date/time format. Prefix approximate times with ~ and note basis. Attribute each entry's source. Add, remove, or reorder rows as appropriate. Integrate witness observations with attribution. If no witnesses, note "No witnesses identified" in lieu of witness row.)

Time	Event	Source
[Time]	[Incident occurred / discovered at location]	[Observed / Reported / System / Video]
[Time]	[Staff notified; first responder arrived]	[Source]
[Time]	[Initial assessment started]	[Source]
[Time]	[First aid/intervention performed: description]	[Source]
[Time]	[Decision made to activate EMS by name/role for objective reason]	[Source]
[Time]	[911 called by name/role, callback number]	[Source]
[Time]	[Witness observation: Per name/role: objective description]	[Reported]
[Time]	[EMS arrived on scene]	[Source]
[Time]	[EMS reached patient]	[EMS]
[Time]	[Patient departed scene with EMS]	[Source]
[Time / Unknown]	[Arrival at destination]	[Source]
[Time]	[Guardian notification attempt: method, outcome, message left, next step]	[Source]
[Time]	[Internal notification: parties notified]	[Source]

Observations and Clinical Status

(Brief, objective facts only; source-attributed. Do not include diagnostic reasoning.)

Symptoms Reported: [Patient-reported symptoms with direct quotes when material]

Observed Signs: [Mental status, gait, speech, visible injuries, other objective findings]

Vital Signs:

• [Time] — [Method]; [BP], [HR], [RR], [SpO2], [Temp], [Pain score]
• [Time] — [Repeat set as applicable]

Relevant History Known at Time: [Allergies, anticoagulants, seizure disorder, etc. / Unknown at time of report] (Do not add information obtained retrospectively.)

Actions Taken (Pre-EMS)

(List interventions performed prior to EMS arrival with timestamps. Include source of any medical direction received.)

• [Time] — [Intervention performed] — Response: [improved / stable / worsened / unchanged]
• [Time] — [Consulted name/role for medical direction; instructions received]
• (If no interventions: "No interventions prior to EMS arrival; patient monitored.")

Consent and Notifications

Consent for Care/Transport: [Who consented], [method: in-person / phone], [time], [scope: assessment / treatment / transport], [interpreter used: Yes / No] (If obtained without delay: "Consent obtained from [person] at [time] without delay.")

Guardian Notification Log: (Include for minors, individuals lacking capacity, or when transported off-site.)

• [Time] — [Number/method] — [Reached / Voicemail / No answer] — [Message left] — [Next step]

Emergency Exception: [Specific emergent condition], [why delay unsafe], [why guardian unavailable] (Include only if care proceeded without consent.)

Refusal of Care/Transport: [Who refused], [capacity assessment], [risks explained], [alternatives offered], [witnesses present], [direct quote of refusal if available] (Include only if applicable.)

EMS Details

Activation: [Objective trigger(s) for EMS activation]; Decision by: [name/role]

Dispatch: [Time called], [Caller], [Callback number], [Dispatcher instructions received]

EMS Unit: [Agency], [Unit ID], [Level of care: BLS / ALS], [Crew names if provided]

EMS Times: Arrived on scene: [time] / Patient contact: [time] / Depart scene: [time] / Arrive destination: [time] / Transfer complete: [time]

Care Provided by EMS: [Interventions and patient response, per EMS report]

EMS Canceled: [Cancellation time], [Reason], [Who canceled] (Include only if EMS was activated then canceled.)

Handoff and Transfer of Care

(If no transfer occurred: "No transfer; remained under care of [name/role]." Omit remaining fields.)

Receiving Party: [Name/role], [Facility/destination], [Contact information]

Handoff Time and Method: [Time], [Face-to-face / Phone / Radio / Written]

Information Communicated (IMIST-AMBO):

• I — Identification: [Name, age, sex]
• M — Mechanism: [Description of event]
• I — Injuries: [Observed injuries]
• S — Signs/Vitals: [Most recent vital signs and key observations]
• T — Treatment: [Pre-EMS and EMS treatments provided]
• A — Allergies: [Known / Unknown]
• M — Medications: [Known / Unknown]
• B — Background: [Relevant history known at the time]
• O — Other: [Other pertinent details]

Items Transferred: [Belongings, medication list, emergency contacts, copies of forms]

Disposition and Follow-Up

Disposition: [Transported by EMS to destination / Released to guardian / Returned to activity / Sent home / Remained for observation]

Restrictions/Safety Plan: [Immediate activity restrictions or precautions]

Notifications Completed: [Parties notified with times]

External Reporting: [Law enforcement / Child protective services / Workplace injury reporting]: [Completed / Not applicable]

Planned Follow-Up: [Callback to guardian, outcome information, equipment lockout, debrief scheduling]

(Do not include root cause analysis, blame statements, or preventability conclusions.)

Attachments

(Omit this section entirely if no attachments exist.)

• [Attachment description] — [Where stored] — [Who collected] — [When]

Attestation

Reporter Attestation: "I attest this report reflects my observations and the sources indicated."

Signature: [Name, title, date/time]

Supervisor Review: [Name, date/time] (Include only if required by policy.)

Addendum

(Include only if amendments are made after initial completion. Do not overwrite original content.)

• [Date/time] — [Author] — [What changed] — [Why]