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2. Incident
4. Date and Time*
   Date and Time

   Date and Time
6. Department
7. City of Incident*
9. Specified Location *
13. Citizen Information
15. Name*
16. Date of Birth*
    Date of Birth
18. Address*
20. City*
21. State*
22. Zip Code*
26. Incident and Injury Description
28. Body part(s) and type(s) of injury (i.e., bruises on front and outside of right knee):*
30. What was the citizen doing at the time of the injury?*
32. How did the incident/injury occur?*
34. How could the injury have been prevented?*
38. First Aid
40. First Aid:*

    1. Accepted
    2. Declined
    3. Not Needed
42. 1st aid given by - Name
44. Comments
48. Transport
50. Time citizen departed County facility
    Time citizen departed County facility
51. Means of Transportation:

    1. Ambulance
    2. Own Vehicle
    3. Other Vehicle
53. If ambulance was used, please list the name:
55. Destination:

    1. Home
    2. Hospital
    3. Other
57. If transported to hospital, which one?
61. Statement(s)
63. Injured citizen's description of incident*
65. Citizen's printed name*
67. Witness description of incident
69. Witness printed name
71. Witness home/cell phone
72. Witness relation to citizen
76. Report
78. Completed by*
79. Reviewed by*
Leave This Blank:


81. 1. Receive an email copy of this form.
82. Email address

    This field is not part of the form submission.

83. Submit

* indicates a required field