EmailMe Form - Accident, Incident, 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/CAMTS Global 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/CAMTS Global, 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 *

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Type Name *

First Last