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2. Incident Date*
   Incident Date
3. Incident Number*
5. BLS Procedures

   Choose procedure(s) from the following:

   1. Cardiac Arrest
   2. Respiratory Arrest
   3. STEMI
   4. RSI
   5. Hospital Interfacility Transfer
   6. BLS Med: Epi-Pen
   7. BLS Med: Naloxone
   8. BLS Med: Albuterol/Atrovent Nebulizer
   9. King Airway
   10. CPAP
   11. Lucas 2 Mechanical CPR
   12. Tourniquet
6. ALS Procedures

   Choose procedure(s) from the following:

   1. Cardiac Arrest
   2. Respiratory Arrest
   3. STEMI
   4. RSI
   5. Hospital Interfacility Transfer
   6. Bradycardia ACLS Treatment
   7. Tachycardia ACLS Treatement
   8. Epi-Pen (used from BLS kit)
   9. Naloxone (used from BLS kit)
   10. King Airway
   11. CPAP
   12. Intubation
   13. IO
   14. Surgical Cricothyrotomy
   15. Chest Decompression
   16. Pacing
   17. Cardioversion
   18. Lucas 2 Mechanical CPR
   19. Tourniquet
   20. CYANOKIT
   21. CareVent Portable Ventilator
8. Brief Incident Description*
   Please give a brief description of the incident/procedures. Do NOT include any patient identifiers or PHI.
10. Provider Name*
11. Provider Phone
12. Provider Email Address
14. I wish to have my call reviewed for follow-up.*

    1. Yes
    2. No
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16. 1. Receive an email copy of this form.
17. Email address

    This field is not part of the form submission.

18. Submit

* indicates a required field