Step 1 — Select Agency
Is this an NCEMS or FD13 incident?
Before You Begin
Does this involve any condition needing immediate or presumed hospitalization?
- Severe respiratory distress
- Major cardiovascular event (heart attack, cardiac arrest)
- Major trauma — open fracture or internal injuries
- 2nd or 3rd degree burns with significant body surface area
- Any event anticipating surgery
- Fatality or probable fatality
- Amputation or loss of an eye
STOP
Notify Your Supervisor Immediately
Call one of the following now:
Has this been accomplished?
The on-duty Chief Officer must complete all paperwork and notify L&I within 8 hours of any serious injury or hospitalization.
All minor reporting events may use the Exposure Report as a Record Only process and may be upgraded to a Workers' Compensation Claim at any time.
Report Submitted
Your incident report has been saved and the on-duty chief has been notified.
Reference Number
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If seeking medical treatment, obtain an Activity Prescription Form (APF) from your provider and return to the Chief as soon as possible.
If signs or symptoms appear within 48 hours, immediately contact your on-duty BC.
Step 1 — What happened?
Step 2 — Answer These Questions
Medical Attention
Question 1: Is this a medical issue that needs professional treatment right away, or can it wait?
Question 2: Presumably, can this be treated without a hospital stay?
Exposure vs. Contamination
Contamination: Contact with a biological substance that does NOT meet exposure criteria. Requires decontamination and documentation.
Exposure: Contact with blood, body fluids, or airborne pathogens capable of transmitting disease. Requires the full Biological Exposure Procedure immediately.
Exposure: Contact with blood, body fluids, or airborne pathogens capable of transmitting disease. Requires the full Biological Exposure Procedure immediately.
Bloodborne — Contamination Questions
Did blood or body fluids splash onto your intact skin?
Did blood or body fluids soak through your clothing?
Did blood or body fluids land on your glasses or mask?
Bloodborne — Exposure Questions
Did visible blood splash into your eyes, mouth, or nose?
Did visible blood get into an open wound (weeping or bleeding)?
Were you punctured by a needle contaminated with blood?
Were you cut by a surface known to have blood on it?
Airborne — Contamination Questions
Did a patient cough on you while wearing PPE?
Did you physically carry a patient while wearing PPE?
Did you get mucosal secretions on your skin?
Did you start an exam without PPE then expand protection when you learned the patient may have a contagious airborne disease?
Airborne — Exposure Questions
Did a patient cough or sneeze in your unprotected face?
Did you spend time in an enclosed, unventilated area with the patient without PPE?
Did you perform airway procedures or respiratory treatments without PPE?
If signs or symptoms appear within 10 days of any biological contact, immediately contact your on-duty BC.
Chemical Exposure — Answer All Questions
Hazardous substances include cleaning products, disinfectants, fuels, fire suppression agents, diesel exhaust, smoke, or any unknown substance on scene or at station.
Was a hazardous substance inhaled?
Was a hazardous substance absorbed through or in contact with skin or mucous membrane?
Was a hazardous substance ingested?
Are you displaying signs or symptoms consistent with a hazardous substance exposure?
Were these signs or symptoms noticed within 48 hours of the potential exposure?
All answers are No. If any signs or symptoms are noted within 48 hours of this event, please create a new incident report immediately.
Step 3 — Complete the Incident Report
No medical attention required — filed as Record Only. You may upgrade to a Workers' Compensation Claim at any time.
Possible hospitalization indicated — notify the On-Duty Chief immediately. L&I must be notified within 8 hours.
Employee & Report Information
Incident Information
Will You Seek Medical Treatment? *
Contact your on-duty BC or Chief to coordinate medical evaluation:
Nature of Injury / Illness
Activity at Time of Incident
Body Part(s) Affected
Biological Exposure Details
Examples: flush exposed skin or eyes with water for 15+ minutes, wash with soap and water, remove and bag contaminated clothing/PPE, clean gear and equipment per agency SOP.
Inhalation: Breathing in particles/vapors.
Absorption: Through skin or mucous membrane.
Ingestion: Swallowed.
Body Fluid: Direct contact with blood or OPIM.
Absorption: Through skin or mucous membrane.
Ingestion: Swallowed.
Body Fluid: Direct contact with blood or OPIM.
Bloodborne: HIV, Hepatitis B/C, or pathogens in blood or OPIM (Other Potentially Infectious Materials = semen, vaginal secretions, CSF, synovial/pleural/pericardial/peritoneal/amniotic fluid, or any body fluid visibly contaminated with blood).
Airborne: Respiratory droplets — TB, COVID-19, etc.
Airborne: Respiratory droplets — TB, COVID-19, etc.
Chemical Exposure Details
Examples: move to fresh air, flush exposed skin or eyes with water for 15+ minutes, remove contaminated clothing, wash affected area with soap and water, follow the product SDS guidance.
I certify that the information in this report is true and complete to the best of my knowledge. I understand I will be asked to provide a signature on the completed form.
Please complete all required fields.
This report is for internal safety, operational review, risk management, and administrative follow-up. Personnel shall provide factual information only.
Before continuing:
- Ensure scene safety
- Request additional resources if needed
- Provide patient care priorities
- Notify supervisor / BC immediately
- Do not speculate or admit fault
I understand this report requires factual information only. I will not admit fault, assign blame, speculate, or discuss liability.
You must acknowledge the statement above before continuing.
Vehicle Incident Quick Assessment
1. Was anyone injured? *
Crew · Patient · Civilian
2. Was a patient onboard? *
3. Was the vehicle responding emergent (lights / siren)? *
4. Was law enforcement notified? *
5. Is the vehicle drivable? *
6. Was there damage to another vehicle or property? *
7. Did the incident occur while backing? *
8. Was a spotter used? *
9. Was there contact with another vehicle or object? (or near miss only) *
10. Has a Chief Officer been notified? *
Contact a Chief Officer now before completing this report.
11. Does this incident require immediate removal from service? *
Incident Basics
Vehicle & Scene Conditions
Incident Type (check all) *
Photo Documentation
Take photos using your agency-issued phone only. Photograph all vehicle damage, scene conditions, and relevant evidence before the scene is cleared. Submit photos separately to your BC.
Factual Narrative *
Factual sequence only. Do not admit fault, assign blame, speculate, or discuss liability.
Notifications
I certify that the information in this vehicle incident report is true and factual. I have not speculated, admitted fault, or assigned blame.
Please complete all required fields.
Vehicle Report Submitted
Report saved. The on-duty BC has been notified.
Reference Number
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Chief / BC Access
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About
NCEMS · FD13
On-Duty Incident Report
Version: 2.9 (build 2026-08-07) · Cloudflare storage
Created by: D. Boyce
Organization: North Country EMS / Clark Fire District 13
Policy Reference: Injury Reporting
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