Monroe County
Emergency Medical Authority
Incident Report
Paramedic
EMS Ambulance
Hospital
Fire Department
Law Enforcement
Other
Date of Incident
Time of Incident
Location of Incident
Nature of Incident
Agency Involved
Person(s) Requesting Investigation
Explanation of Incident
Reason for Investigation
Date
Name
Title/Agency
Address
Phone
E-mail
PLEASE REMIT REPORT WITHIN 10 DAYS OF INCIDENT
