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2. Emergency Service

   1. Emergency Medical Services (EMS) Ambulance
   2. Fire Department
   3. Hospital
   4. Law Enforcement
   5. Paramedic
   6. Other
4. If other:
6. Date of Incident
   Date of Incident
7. Time of Incident
   Time of Incident
9. Location of Incident
11. Nature of Incident
13. Agency Involved
15. Person(s) Requesting Investigations
17. Explanation of Incident
19. Reason for Investigation
21. Date
    Date
23. Name
25. Title / Agency
27. Address
29. City
30. State
31. Zip Code
33. Phone
34. Email
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36. 1. Receive an email copy of this form.
37. Email address

    This field is not part of the form submission.

38. Submit

* indicates a required field