Incident Report

SAN JUAN COUNTY FIRE/EMERGENCY SERVICES

INCIDENT REPORT

REPORT #

ODOMETER READING
BEGINNING @ SCENE
ENDING
TOTAL MILES

DEPARTMENT
IC
DATE:
UNIT #

LOCATION OF INCIDENT:

TYPE OF INCIDENT
FIRE
WILDLAND
STRUCTURE
AUTO
ENROUTE 10-39

EXTRICATION
RESCUE
OTHER
LIST
10-40

Time Paged Out:
Time In Route:
Time Out @ Scene:
Time Done @ Scene:
Time Completed:

PERSONNEL ON SCENE: (Agency Only)

SUPPLIES USED:

EQUIPMENT PROBLEMS:

DESCRIBE RESPONSE:
Investigating Agency and Officer:
EMS on Scene Yes No If yes Unit(s) EMS Incident #
Name and Address of Responsible Person and/or Owner:
Insurance Company and Address:
Policy Number: