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IDHS > About IDHS > Training & Exercise > EMS Provider Vehicle Accident Reporting EMS Provider Vehicle Accident Reporting

In compliance with IAC 836, all Certified EMS Providers must submit a vehicle accident report as required by the EMS Commission when a provider vehicle is involved in a motor vehicle accident. Reports must be received within 10 working days following the accident. It is the responsibility of the organization CEO to make sure that the report is filed in a timely fashion and completed in its entirety. Failure to comply will result in enforcement of the penalties outlined in IC 16-31-3.

* 1. Please provide the following information:
EMS Agency Name:
EMS Agency Certification Number:
Certification Number of Vehicle Involved in Accident:

* 2. Type of Vehicle:
Ambulance
Non-transport
Other (please specify):

* 3. Please provide the time of the accident:

 
MM DD YYYY HH MM AM/PM
Time of Accident / / :

* 4. Please provide the location of the accident:
State of Accident
County of Accident
City of Accident

*5. Please provide the following information regarding the crew members:
# of Crew Members in Ambulance
Name of Crew Members in the Ambulance at the time of the Accident:

 
First Name Middle Name Last Name

If you have additional crew member names to submit, please indicate YES below:

* 6. Please provide the following information regarding the driver of the ambulance:

 
First Name Middle Name Last Name
Driver's Name
Driver's Date of Birth: (MM/DD/YYYY)
Driver's Age:
Driver's PSID #: (Correct Format XXXX-XXXX)
Email Address:
Retype Email Address:

* 7. What type of emergency driver training has the driver had?
Formal training (CEVO, EVOC)
Provider Based Training (In-house developed and taught program)
None

* 8. When was the last time the driver took any type of emergency driver training?
1. Less than a year ago
2. 1-2 years ago
3. 2-5 years ago
4. Greater than 5 years ago
5. Never

* 9. How many years of general driving experience does the driver have?
1. Less than 1 year of experience
2. 1-2 years of experience
3. 2-5 years of experience
4. Greater than 5 of experience

* 10. How many years of AMBULANCE driving experience does the driver have?
1. Less than 1 year of experience
2. 1-2 years of experience
3. 2-5 years of experience
4. Greater than 5 of experience

* 11. Was the driver restrained?
Yes
No

* 12. Was the Driver Operating in Emergency Mode at the time of the accident?
Yes
No

* 13. Please select what emergency equipment they were reported using:
Lights
Sirens
Both
None

* 14. ACCIDENT DETAILS
The emergency vehicle was:

Responding to a scene
On the scene of a call
En route to a medical facility
Returning to a station or post
Other (please specify):

* 15. Was there an investigation by a law enforcement agency?

*16. Please describe the damage to any or all of the following: (if no damage, leave field blank):
Property
EMS Vehicle
Other Vehicle
Other

* 17. Were there any patients on board at the time of the accident?

* 18. Please describe the number and types of injuries and/or fatalities:
No reported Injuries and/or Fatalities
EMS Crew
Civilians or bystanders
Patient in ambulance
Other Vehicle Occupants

*19. Explain how the accident occurred:

20. Any additional comments (optional):

* 21. What was the length of the shift the crew was working?
4 hours
8 hours
10 hours
12 hours
16 hours
24 hours
Other (please specify)

* 22. How many hours into the shift was the crew when the accident occurred?

* 23. How many hours had it been between the end of the driver’s last shift and the beginning of the driver’s shift when the accident occurred?

* 24. How many total calls had the crew responded to prior to the accident (transport, cancelled, SOR, etc.)?

* 25. Had the crew had any breaks during the shift prior to the accident? (A break is defined as an uninterrupted period of time where the crew was not working, traveling, driving, or engaging in any work related operations.)