First

FIRST RESPONDER FORM Request call review

FIRST RESPONDER:
STATE OF CONNECTICUT

FR
EMS
FIRE DEPARTMENT OF PUBLIC HEALTH
POLICE
OTHER
OFFICE OF EMERGENCY MEDICAL SERVICES
PATIENT CARE REPORT
NAME OF SERVICE: UNIT #: SERVICE PROVIDER CERT #: INCIDENT / CASE #:

DISPATCH DATE: DISPATCH TIME: ENROUTE TO SCENE: ARRIVAL ON SCENE: DEPARTED SCENE: RETURNED TO SERVICE:

NATURE OF CALL: CHIEF COMPLAINT:

INCIDENT LOCATION: STREET & TOWN: CITY: STATE: ZIP CODE:

PATIENT NAME: DOB: AGE: SEX: SOCIAL SECURITY #:

ADDRESS: APT / ROOM #:

CITY / TOWN: STATE: ZIP CODE:

VEHICULAR TRAUMA: IMPACTING: OCCUPANT OF: EXTRICATION FROM: PATIENT PROTECTIVE DEVICES:
DRIVER AUTO AUTO NO EXTRICATION NONE
PASSENGER TRUCK TRUCK REQUIRED SEAT BELT
PEDESTRIAN TREE / POLE BUS VEHICLE AIRBAG – FRONT
NON-VEHICULAR TRAUMA OTHER MOTORCYCLE BUILDING AIRBAG – SIDES
OTHER BICYCLE REMOTE PLACE CHILD SEAT
OTHER OTHER OTHER

NON-VEHICULAR TRAUMA TYPE: SET #: 1 2 PUPILLARY RESPONSE: COMMUNICATION BARRIER: MEDICATIONS (LIST):

FALL >6 FT TIME: L R LANGUAGE

FALL <6 FT EQUAL DEAF
GUNSHOT LOC: UNEQUAL MUTE
KNIFE REACTIVE TO DEAF & MUTE
LIGHT
ATHLETICS RESP: BLIND
NON –
DOMESTIC VIOLENCE DEVELOP. DISABILITY
REACTIVE
ELECTRICITY BP: OTHER ALLERGIES (LIST):
INDUSTRIAL / MACHINERY
OTHER PULSE:

PPE: VITAL SIGNS NOT ALLOWED NAME OF GUARDIAN (IF PATIENT IS A MINOR):
YES BY PATIENT (EXPLAIN IN
NO NARRATIVE)

PATIENT REASSURANCE: SPLINTING: OXYGEN ADMINISTERED? EPI-PEN ADMINISTERED? CPR PERFORMED: AED USED?
YES YES YES __________ L / M YES YES YES
NO NO NO NO NO NO

NAME FIRST RESPONDER (PRINT): TIME OF DEFIB:

FIRST RESPONDER SIGNATURE:

NUMBER OF SHOCKS:

FIRST RESPONDER CERTIFICATION #:

PULSE RETURNED:
NAME SECOND RESPONDER (PRINT): YES
NO
TIME:
SECOND RESPONDER CERTIFICATION #:

NARRATIVE: