MIRF Medical Incident Response Form Complete the form below to the best of your ability. Medical Incident Response Form Name of Reporting Team Member Type of Incident Campus Carlsbad Fallbrook Ramona Rancho Bernardo San Marcos/Escondido Vista Location/Building Adult Mod A Adult Mod B Building 1 (Main Restrooms) Building 1A (Live Venue) Building 18 (Pre-School) Building 2 (Warehouse) Building 3 (K-Jr. High) Building 4 (Admin) Building 5 -The Edge Buildings (All) Camp - Off Site Exterior HS -11/12 HS -9/10 Learning Center Parking Lot - Building 7 Parking Lot - High School Parking Lot - Top Parking Lot A Parking Lot B Parking Lot C Parking Lot D Parking Lot E Parking Lot F Plaza - Main Plaza - Ramp Plaza - Stairs Plaza Water Fountains Satellite CBD Satellite FBK Satellite RMA Satellite SME Vista Other If other, describe location Date of Incident Time of Incident 121234567891011 : 000102030405060708091011121314151617181920212223242526272829303132333435363738394041424344454647484950515253545556575859 AMPM Number of Patients for this Incident List Patient(s) Name, Age, Parent/Guardian (if under 18), Parent/Guardian Phone # Describe Medical Event / Actions taken by team List Name(s) of NCS team members Involved Was medical attention accepted? Yes No Medical attention was refused by (name and relationship to victim) Was 911 emergency service called? Yes No Was patient transported via 911 emergency services? Yes No What hospital was victim transported to? Palomar Tri-City Scripps La Jolla Other What hospital was victim transported to? NCS team lead Calhoun, Jeff Cantor, Greg Ducat, Brad Epenesa, Tony Ephron, Matt Flood, Gregg Garrett, Scott Gleason, Terrence Gonzales, Florante Green, Bill Greenberg, Jeff Hanks, Mike Hardy, Ron Kaiser, Mike King, Jason Knowles, Wes Kos, Mike Meyerholz, Daniel Moy, Tim Nolasco, Gabe Perry, Vic Ridenour, Jim Rivero, Rick Robertson, Jeff Rossall, Scott Sterling, Bob Vicent, Ron Watt, Alan Weese, Bill White, Frank Other If other, please inlcude team lead's name Submit If you are human, leave this field blank.