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Ambulance Collision Report

       North Dakota Department of Health
       Division of Emergency Medical Services
       600 E. Boulevard Ave. Dept. 301
       Bismarck, ND 58505-0200

                                                                                                                            

The following information is required to be reported under N.D.A.C 33-11-01.2-10. The information submitted will be used for data collection purposes so that we may determine future needs of EMS in North Dakota. This information must be reported within thirty days of incident that involves personal injury or property damage of more than one thousand dollars.

Please complete this report and submit it to the North Dakota Department of Health when there has been an ambulance collision resulting in over $1000 in damage.


Incident Date:

PM

 

 

 

 

Yes No

Yes No

Yes No

Critical Stable Minor N/A

Road Conditions:



Yes No
 

Yes No

   Red Lights Siren None Both

Yes No

Did Yes No

 

 





Thank you for your assistance.

The information submitted here is for data collection purposes in order to determine future needs of EMS in North Dakota and is mandated under N.D.A.C. 33-11-01.2-06. Please do not leave any areas blank and answer all questions to the best of your knowledge. You may be contacted if more information is needed. p>



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Copyright 2005 North Dakota Department of Health

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