EmailMe Form - CAMTS Accident, Incident and Sentinel Event Report

Name of the medical transport service *

Aviation or ambulance operator *

Name of person reporting *

First Last

Email *

City and State of home base *

Date and time of accident, incident, or sentinel event *

MM / DD / YYYY HH : MM AM/PM

Location and circumstances of the accident/incident/sentinel event (not necessary if any of the above-described reports
are included)

Names of personnel and/or patients suffering minor, serious or fatal injuries. - Include name, position (i.e. RN, pilot, patient) and type of injury. *

Describe the immediate changes in aircraft or ambulance, new hires and any other operational
changes resulting from the Accident, Incident, or Sentinel Event. *

CONCERN Report / other attachments

The undersigned understands and acknowledges that, to the extent the Accident or Sentinel Event involved a fatality, CAMTS will require a supplemental Site Survey /Monitoring Visit or Reaccreditation Site Survey. The date and time of said visit is at the sole discretion of CAMTS, and may occur at any time within six (6) months of the Accident and may be unannounced. The undersigned further agrees and acknowledges that, in the event of a fatal Accident or Sentinel Event resulting in a death , the program will immediately be placed Under Review status, as defined in Policy 04.01.00(c), until the supplemental Site Survey/Monitoring Visit/ Reaccreditation Site Survey is completed and the findings are reviewed by the Board.

Signature *

Clear

Type Name *

First Last