Orange County NC Website
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FIRST CHOICE MEDICAL TRANSPORT <br /> INCIDENT REPORT <br /> WHAT <br /> Was this an actual or near miss event Actual_Near Miss/Close Call <br /> What happened? <br /> Anything else we should know about the event? <br /> WHEN/WHERE <br /> Date of Occurrence:_/_/ _Date unknown <br /> Time: Time unknown <br /> Where did this occur?&Whom was Present? <br /> WHO <br /> Patient Staff Both <br /> Name of person involved:Last ,First <br /> Gender: M F <br /> DOB: / / <br /> Telephone#:( ) - <br /> Mailing Street Address 1: <br /> Mailing Street Address 2: <br /> City: State: Zip: <br /> Page 1 of 2 <br />