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)