East County On Line Call Report
E-mail Address:
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Volunteer Name
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Date of Call
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Start Time
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Response Time
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End of Call Time
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Total Time on Call
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Scene Location
Home
Hospital
Accident Site
Other
Describe Other Location
Scene Address
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Requesting Agency
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Agency on Scene
Emergency Responder Names
ME Case
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Yes
No
ME Name
Waiver Number
Incident Number
Victims Name
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Victims Sex
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Male
Female
Age
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Primary Clients Name
Primary Clients Address & City
Primary Clients Phone#
Ethnicity of Client
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Relationship to Victim
Additional Clients
Additional Clients Address
Total Number of Clients
Support Family - Senior Death
Support Family - Death
Suicide or Attempt - Adult
Suicide or Attempt - Child
Accidental Death
Medical Emergency
Anxious or Depressed Citizen
Death Notification
Support Fire Victims
Support Rape Victim
Disoriented Older Person
Domestic Violence
Assault Victim
Crime Victim
SIDS
Child Death Under 18
Auto Accident
Death
Injury
Auto vs Pedestrian
Death
Injury
Drowning
Child
Adult
Drug Overdose
Homicide
Other
Describe Other
Emotional Support
Practical Support
Mortuary/Cremation Services Info
Made Necessary Phone Calls
Info on ME Protocol
Liaison w/ Emergency Services Personnel
Facilitated Saying Goodbye
Contacted Referrals
Waited on Scene until Body Removed
Final Details
Provided Resource Guide
Grief Literature
Funeral Goods or Services
Trauma Scene Clean Up Information
Info on Being Alone
Survivors of Suicide
SIDS Support
Childrens Grief Material
TIP Information
Bear
Other
Describe Other
Comments:
What I Learned on this Call
Comments I would like to make to the emergency responder on scene:
*
Required