Ambulance Collision Reporting Users` Manual
Contents
1. 12 Alberta Health Ambulance Collision Report User s Manual Prepare and send the Collision Report to EHS 1 Hit the SAVE button at the bottom of the form to save all the information you have entered 2 Hit the SUBMIT button at the bottom of the form to email the PDF to Emergency Health Services Then follow these steps e Select the type of email system you are using from the pop up box that appears on bench Please indicate the option which best describes how you send mail Standing Zone 10A Desktop Email Application Zone 10B Choose this option if you currently use an email application such as Microsoft Outlook Zone 10C Express Microsoft Outlook Eudora or Mail Zone 10D Internet Email 11 Out of Unit Choose this option if you currently use an Internet email service such as Yahoo or Microsoft Hotmail C Other ee eee ya do not know which option e Lx l_a e Click on Send Data File in the next pop up box that appears alae i Click Send Data File to switch to your email dient and send the form s data file The form itself is not sent 11 Out of Unit Please print your completed form if you would like a copy for your records T parison aan Save Print preron _ comeet e The email will be automatically prepared and formatted to be sent to EHS Click on Send 3 Hit the PRINT button at the bottom of the form if you want to print a copy for your files 13 20132. Obscured unable to be seen or distinguished due to snow mud branches other vehicle etc Road Alignment Straight amp level Straight with grade Straight at hillcrest Curve amp level Curve with grade Curve at hillcrest Other N A Click on Choose to activate a Drop Box 2013 Government of Alberta Alberta Health Ambulance Collision Report User s Manual Road Surface Type Asphalt Oiled Concrete Gravel Soil sand Other N A Click on Choose to activate a Drop Box Road Surface Condition No unusual conditions Construction maintenance Holes ruts washboard Slippery when wet Soft sharp shoulders Other N A Click on Choose to activate a Drop Box Road Surface Factors Dry Wet Slush snow ice Loose surface material Muddy Other N A Click on Choose to activate a Drop Box Primary Weather Conditions e Clear Cloudy Rain Freezing rain Hail sleet Snow Fog smoke dust Click on Choose to activate a Drop Box Wind Factors e Calm e Breezy e High Wind Click on Choose to activate a Drop Box Temperature Degrees Celsius Fill in the blanks 2013 Government of Alberta Alberta Health Ambulance Collision Report User s Manual Light Conditions Click on Choose to activate a Drop Box Daylight Sun glare Dawn dusk Dark unlighted roadway Dark lighted roadway
3. Other e N A Ambulance Actions Prior e Going straight Click on Choose to activate a Drop Box Follow curve left Follow curve right Turning left Turning right Passing on left side Passing on right side Backing Making U turn Parked Leaving curb Changing lanes Stopped in traffic Avoiding a vehicle Avoiding animal on road Avoiding object on road Stopped at scene with lights Stopped at scene without lights Other e Unknown Driver Actions Prior Click on Choose to activate a Drop Box e No inappropriate actions e Proceeding against traffic control with lights and siren e Proceeding against traffic control with lights only e Stop sign violation e Yield sign violation e Fail to yield right of way uncontrolled intersection e Fail to yield right of way to pedestrian Follow too close Left turn across path Improper turn Improper passing Unsafe lane change 2013 Government of Alberta Alberta Health Ambulance Collision Report User s Manual Driver Actions Prior cont Lost control gt Driving left of centre line Backing gt In parked vehicle Out of vehicle Other Unknown Tf Lost Control is chosen another field will appear Uncontrolled skid Off road to left Off road to right If Backing is chosen another field will appear With guide Without guide Primary Collision Event Hit at an angle side i
4. Government of Alberta
5. On call hours e Other occupation Fill in the blank for each of 3 fields Scheduled hours on duty at station If required to be on call outside core hours Hours at a non EMS job Driver Information cont of kilometers driven in ambulance e Since last rest period of 210 hours e In past 24 hours e In past 48 hours Fill in the blanks for each of 3 fields Defensive driving course taken in past 24 months If Yes is chosen 2 further fields will appear Provider Type External Provider In house course Instructor Qualifications Cda Safety Council Certified Other 2013 Government of Alberta Alberta Health Ambulance Collision Report User s Manual Prof Driver Improvement Course taken in past 24 months If Yes is chosen 2 further fields will appear Provider Type External Provider In house course Instructor Qualifications Cda Safety Council Certified Other Emergency vehicle operation course If Yes is chosen 1 further field will appear Provider Type External Provider In house course Incident Statistics Road Type Primary highway Secondary highway Urban arterial road Business commercial road Service road Residential street Driveway Lane alley Rural road Other N A Select the most appropriate response Urban arterial road any main thoroughfare in an urban area Business commercia
6. side Left front Front end Roof perimeter or top Undercarriage Not applicable Click on Choose to activate a Drop Box Ambulance Passenger Information Type of passenger e EMS 1 Driver EMS 2 Attendant EMS 3 Attendant Patient 1 Patient 2 Escort 1 Other Pass Escort 2 Other Pass Second attendant if present Medical escort family member etc Extent of injury Minor Major Fatal None If Minor Major or Fatal are chosen 2 more fields will appear Mechanism of Injury Chose appropriate one from drop down list Area of Injury Check all that apply Wearing Seatbelt e Yes e No e N A Check appropriate box Air Bag Deployed e Yes e No e N A Check appropriate box If an error is made in selecting a response the RESET button allows you to start again 2013 Government of Alberta 11 Alberta Health Ambulance Collision Report User s Manual Location in ambulance pre collision Use the diagram to record the pre collision location of each person in the ambulance Enter the location codes on the chart If Patient 2 was on the second main cot in a dual cot modular enter 6 If Patient 2 was transported laying on the squad bench enter 789 If any attendant or passenger was standing in the patient compartment at the time of the collision enter the correct number for the zone in which they we
7. Alberta Health Ambulance Collision Report User s Manual Ambulance Collision Report Users Manual Completing an Ambulance Collision Report HS0237 is mandatory for any collision involving the ambulance alone or with another vehicle person or object when that collision a results in injury or death to any person in the ambulance b occurs while the ambulance s emergency warning lights or siren are activated or c results in property damage greater than 5 000 Ref EHS Policy 2008 01 Rev 3 July 2 2013 Instructions for Completion of Ambulance Collision Report This is an interactive e Form Refer to the following when completing the Collision Report 1 To open a form e Go to the EHS web site http www health alberta ca services EHS html Click on Operator Forms amp Documents Scroll down to Forms and open the Ambulance Collision Report form Save a copy to your hard drive Name the copy with your Operator ID and the collision date IE 3249 2008 03 21 2 Some fields ask for information to be entered type the answers in the blanks 3 Where Choose is shown in a field click on the down arrow button at the right side of the field to activate a Drop Box Pick the response that best applies 4 Some fields have lists with check boxes e On most lists you may check all choices that apply Click on the box es to enter a response If you choose a box in error click on it again to remove the response e I
8. l road roads in any business or commercial area eg downtown Service road any road adjacent to an urban arterial road that allows access to commercial or residential properties Collision Location e Intersection gt e Non Intersection gt Railway Crossing gt If chosen Type field will appear Controlled Uncontrolled If chosen Type field will appear At near commercial entrance At near private entrance At near service road None of the above If chosen Type field will appear Uncontrolled Warning lights Warning lights and cross arms 2013 Government of Alberta Alberta Health Ambulance Collision Report User s Manual Collision Location cont Parking Lot Private Property Ambulance Base Property Off Highway Other Traffic Control Device None present Traffic light Stop sign Yield sign Merge sign Pedestrian crosswalk lights School bus warning lights Lane control Other Click on Choose to activate a Drop Box If None Present is chosen Traffic Control Condition is automatically populated with Not Applicable Speeds e Posted speed limit e Ambulance s estimated speed Fill in the blanks Speed safe for conditions Choose Yes or No Traffic Control Condition Functional Not functional Obscured Missing Other Not applicable Click on Choose to activate a Drop Box
9. mpact by another vehicle Hit another vehicle at an angle side impact Head on Side swipe opposite direction Side swipe same direction Struck from behind Rear ended another vehicle Roll over Struck object on roadway or shoulder Struck object off roadway Struck object while backing Other Unknown Click on Choose to activate a Drop Box Other Vehicle or Object No other vehicle object involved Passenger car gt Pick up van mini van gt lt 4500 kg Truck gt gt 4500 kg Truck trailer combination gt Motor home gt Motorcycle scooter moped gt Bicycle gt Bus school bus gt Train gt Debris object on roadway Fixed object guard rail lamp post building tree rock Pedestrian Animal Construction equipment gt Farm equipment gt Off highway vehicle snowmobile gt Other Click on Choose to activate a Drop Box Single rear wheel pick up Dual rear wheel pick up and above will appear Indicate whether the collision resulted in injury or death to a person who was a passenger in the other vehicle or was a cyclist or pedestrian If any response with gt is chosen another field Any person not in the ambulance injured or killed 2013 Government of Alberta 10 Alberta Health Ambulance Collision Report User s Manual Initial Point of Impact on Ambulance Right front Right side Right rear Rear end Left rear Left
10. n Section 5 Ambulance Passenger Information there is a Reset button in the left column Use this button to correct entry errors 5 Where multiple choices are given in a drop box field you can choose only one 04 07 2013 2013 Government of Alberta Alberta Health Ambulance Collision Report User s Manual 6 Fields displayed in blue are formatted as If Then and additional information box es will appear when certain responses are selected Some choices are multi level and will trigger a second level of detail The second level of detail is signified either with blue text or with an arrow gt Example 1 Responding to a Call Primary Level If YES is chosen then the following choices appear a Emergency Response or b Non emergency Response Secondary Level If Emergency Response is chosen then the following choices appear a Operating with Warning Lights and Siren or b Operating with Warning Lights only Example 2 Collision Location Primary Level Drop box with 8 choices a If Intersection is chosen then Secondary Level a the following box appears Intersection Type and you can choose a Controlled b Uncontrolled AMBULANCE COLLISION REPORT DATA ELEMENTS Incident Number Optional If you maintain records of collisions by creating an internal incident number this space may be used Up to 16 characters are available Operat
11. or ID Enter the 4 digit ID code assigned by EHS EHS Unit Enter the 4 or 5 digit unit number assigned to the ambulance by EHS Collision Date When you enter this field a button appears on the right side Click on it to access a calendar Select the date of the collision Collision Time Enter the time in 24 hour format hh mm Report Type e Fatality Click on Choose to activate a Drop Box e Injury e Lights siren activated e Property damage only 2013 Government of Alberta Alberta Health Ambulance Collision Report User s Manual Section 1 Ambulance Vehicle Information Chassis make Chev GMC Dodge Ford Freightliner Navistar IHC Other Click on Choose to activate a Drop Box 4 wheel drive Choose Yes or No Model year yyyy Enter the 4 digit model year of the chassis Ambulance Conversion Date mm yy only Record the month and year of the conversion as stated on the Certificate of Compliance affixed by the ambulance conversion manufacturer Conversion manufacturer e Crestline Coach Demers McCoy Miller Road Rescue Wheeled Coach Other Click on Choose to activate a Drop Box Conversion Type e Type I e Type II e Type Il Click on Choose to activate a Drop Box Modular built on truck cab chassis Raised roof van conversion Modular built on RV cutaway chassis Modular Body Built yyyy En
12. re standing If the ambulance was parked at a scene or stopped enroute during transport enter 11 for any crew member who was out of the unit when it was struck Do not include patients who had not yet been loaded into the ambulance Back Person Driver EMS Attendant 1 EMS Attendant 2 Patient Patient Escort Other passenger 1 Escort Other passenger 2 2013 Left Front Right 11 Outof Unit Patient 2 Choose HI EMS Attendant 1 Choose HI Choose g EMS Attendant 2 X Patient 1 Choose Escort Other Passenger 1 Escort Other Passenger 2 Choose Choose Ambulance Legend 1 EMS 1 Driver 2 Front Passenger 3 Airway Seat 4 CPR Seat 5 Main Cot 6 2 Cot when no squad bench 7 Squad Bench Rear 8 Squad Bench Centre 9 Squad Bench Front 789 Aux Stretcher on bench Standing Zone 10A Zone 10B Zone 10C Zone 10D 11 Out of Unit Ambulance Location Codes Location Front passenger s seat Secondary main cot if equipped Rear squad bench Middle squad bench 1 Driver s seat 2 3 Airway seat 4 CPR seat 1 _ 5 Main cot 2 6 7 8 9 Forward squad bench 789 Aux stretcher on squad bench 10A Standing left rear 10B Standing left front 10C Standing right rear 10D Standing right front 10 Out of unit Government of Alberta
13. ter N A Response Information cont Transporting Patient Choose Yes or No Multi level choice If Yes is chosen further fields will appear PMD Code Non Emergency Transport Emergency Transport If Emergency Transport is chosen a further field will appear Select either o Warning Lights amp Siren or o Warning Lights Only 2013 Government of Alberta Alberta Health Ambulance Collision Report User s Manual Section 3 Driver Information Driver s Employment Status Full time Part time Casual Non employee Click on Choose to activate a Drop Box Employed full time Scheduled part time or volunteer Arranged shifts work when called Driver not employed by ambulance operator fire fighter police by stander Training Level EMR PCP ACP CCP Non medical Click on Choose to activate a Drop Box EMR in Alberta EMT in Alberta EMT P in Alberta When the driver has no ACP registration Driver s Experience General e Less than 1 year e 1 to 10 years e 10 or more years Click on Choose to activate a Drop Box Refers to the driver s cumulative driving experience since first licensed Driver s Experience Ambulance e Less than 1 year e 1 to 10 years e 10 or more years Click on Choose to activate a Drop Box of hours worked in past 48 hours e EMS Core hours e EMS
14. ter the year that the modular body was originally built Ambulance Vehicle Information cont Vehicle Safety Enhancements Squad Bench Safety Net Rounded Corners Extrusions Padding in Head Strike Zones 3 or 5 point harness Airway seat Body Harness amp Lanyard Protective Head Gear Back up Camera Back up Proximity Alert Operational Recorder Black Box Check all that apply Back up Proximity Alert Automated warning device that lets the driver know if the vehicle is getting too close to an object in its path when backing up Operational Recorder electronic monitor that records vehicle operation parameters 2013 Government of Alberta Alberta Health Ambulance Collision Report User s Manual Ambulance Mechanical Defects No Defect Brakes Tires Suspension Wheels Steering Electrical Failure Fuel System Engine Transmission Lights Unknown Other Check all that apply Section 2 Response Information Responding to a Call Choose Yes or No Multi level choice If Yes is chosen further fields will appear PMD Code Non Emergency Response Emergency Response If Emergency Response is chosen a further field will appear Select either o Warning Lights amp Siren or o Warning Lights Only Priority Medical Dispatch PMD Code Record the PMD card number assigned to the call by Dispatch If PMD is not used en
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