CLARK COUNTY INDIANA EMS ISSUE REPORTING FORM
Your Email Address
*
Name
*
First Name
Last Name
Your Agency if any
*
None
Clark County 911
Other
Date of incident or situation
*
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Month
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Day
Year
Date Picker Icon
Time of incident
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Hour
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Minutes
AM
PM
AM/PM Option
CFS #
INCIDENT TYPE
Type of issue
*
DELAY IN RESPONSE
PATIENT CARE
OTHER
EMS AGENCY
*
AMR
NEW CHAPEL EMS
NEW WASHINGTON EMS
AIR METHODS
AIR EVAC
OTHER
ETA PROVIDED
In Minutes
Actual time lapse of arrival
In minutes
Location of incident
*
Please describe what happened. Be as detailed as possible.
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