Appendix 5-6 AFSC Form 1924 ARE Events Log.pdf

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Holloman AFB Ambulance Response Element N/A

DATE (YYYYMMDD)

PAGE OF PAGESEVENTS LOG

FACILITY REVIEWED BY

TIME TIME

NAME INITIALS NAME INITIALS

TIME CLASS RECORD OF EVENTS

AFSPC FORM 1924, 19940401 (IMT-V1)

Name of EMT-P on shift MOD/On call:

Name of EMT-B on shift FSO:

ALT MOD/On Call:

09B2456: Medic-1

06B238: Medic-4

08B873: Medic-5

0400 911 Medic 1 responded to bld 191 for 54y/o Last Name, First Name. civilian contractor for back pain.

Patient transported to GCRMC-ER....(initials of person placing entry in)

0700 SC Change of shift accomplished; report given, off-going shift released...MW

0852 IFE Medic 5 responded to Runway 16 for a (type of aircraft) with (reason for emergency)

IFE terminated at 1235 without incident. Medics responding: Name and Name....MW

1545 911 Medic-1 responded to bldg 456 for a female with a bloody nose. Last Name, First Name Rank

20/last four of SSN, Squadron. Pt involved in an altercation and was punched in the nose.

Pt signed AMA after getting permission from medical control...BS

0700 EOL No other occurrences on shift; log closed. 0-911; 0-IFEs; 0-Adm; 0-TRANS. Change of shift accomplished, report given, off-going shift released...RS

SC = Shift Change

IFE = In-Flight Emergency

EOL = End of Log

ON OFF ON OFF

SAMPLE

FA4801-11-R-0002

Ambulance Service

10 May 2011 Appendix 5-6 Page 1 of 2

PAGE OF PAGESEVENTS LOG (Continued)

TIME CLASS RECORD OF EVENTS

AFSPC FORM 1924, 19940401 (REVERSE) (IMT-V1)

SAMPLE

FA4801-11-R-0002

Ambulance Service

10 May 2011 Appendix 5-6 Page 2 of 2