Critical Vehicle Failure/Equipment Failure Report

Name of person filling out this form *

First

Last

Phone *

Email *

Failure Type *

Agency Name *

Name/Title of Incident Reviewer *

Incident Date & Time *

Date

Time

All Incident Numbers (including backup ambulance) *

Vehicle #

Mileage

Patient on board? *

Last Preventative Maintenance Date

Last Preventative Maintenance Mileage

Dispatch

On Scene

Transport

Time of Failure

Dispatch

On Scene

Transport

Hosp. Arrival

Was Patient Care Affected? *

Failure Times Information

Equipment involved

Equipment Serial/ID #

Last Preventive Maintenance Date (if biomedical equipment)

Description of Problem/Incident Summary/Actions Taken *