DATE:
A.
TIME:
ACCIDENT
SCENARIO
(How did injury
occur?):
EMERGENCY
MEDICAL
SERVICES
- HELICOPTER AMBULANCE
REQUEST INFORMATION
CAUTION:
EMS
Helicopters
Do Not Usually Carry Extrication Equipment Or Personnel Trained In
B.
INCIDENT
SITE
INFORMATION:
These Procedures; Ensure That This Capability Is Ordered Through Local S&R.
B.
INJURY INFORMATION, TOTAL NUMBER OF PERSONNELTO BE TRANSPORTED:___
PATIENT INFORMATION: AMBULATORY? YES/NO.
3.
2.
4.
1.
Visibility:
Terrain
Conditions
Factors:
At Scene:
Location Of Accident:
Windspeed:_______ Elev:____________ MSL
Temp:___(F/C)
Twn:_________ Rge:________ Section:___________ 1/4 S:
Latitude:____________________ Longitude_________________
NM @
Degrees Off
VCR
5.
Helispot Size And Condition (Is It Completed Or When Will It Be Completed)
6.
7.
Contact Person On Helispot.__________________________________
Is this person Helitack qualified_______________
8.
10.
C
Proximity
Special
GROUND
Information,
Of
CONTACT
HelispotFlight
To
PERSON
Injury
Hazards,
Site
AT SCENE
Etc.:
1.
9.
11
2.
NAME_______________________________
2.
Phone Number:__
:Other Aircraft In Area (Call Signs):
Radio Frequencies::____________________
____________
Frequencies
Primary:
VHF-AM:
VHF-FM:
(Ground
Contact):
Secondary:
VHF-AM:
VHF-FM:
DIVISION OR GROUP_______________________________
3.
HBM-10b
(February, 1992)