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- Station
Run Number
- Record
your Department’s identification number for the current call
- local option.
- Jurisd
Incident Number
- Record
the ECC Incident Number for the current call.
- Supl
- Record
the number of supplements related to the current incident. For example,
the MAIS forms for two persons injured in a motorcycle crash would
each have one supplement. The supplement shows one additional record
was produced for this call.
- Box Number
- The
location identification number for the current call.
MCFRS-EMS
captures this information electronically - leave this section blank.
- District
Record
- DFRS
district number: 001, 002, 003, 004, 005.
- Out
of county response:
- 010
Allegheny County
-
020 Anne Arundel County
-
030 Baltimore County
-
040 Calvert County
-
050 Caroline County
-
060 Carroll County
-
070 Cecil County
-
080 Charles County
-
090 Dorchester County
-
100 Frederick County
-
110 Garrett County
-
120 Harford County
-
130 Howard County
-
140 Kent County
- 160
Prince George’s County
-
170 Queen Anne’s County
- 180
Saint Mary’s County
-
190 Somerset County
-
200 Talbot County
-
210 Washington County
-
220 Wicomico County
-
230 Worcester County
- 240
Baltimore City
- 300
District of Columbia
- 400
Virginia
- 900
Other jurisdiction not listed
- Receiving
Facility
- Record
the name of the receiving facility to which you transported this
patient.
- CHNMC:
Children's Hospital
- HCH:
Holy Cross Hospital
- HCG:
Howard County General
- LG:
Laurel General
- MG:
Montgomery General Hospital
- MIEMSS:
R Adams Cowley Shock Trauma Center
- MSTAR:
MedStar
- SGAH:
Shady Grove Adventist
- SuT:
Suburban Trauma
- SUB:
Suburban Hospital
- WAH:
Washington Adventist Hospital
- WHC:
Washington Hospital Center
- Other Units
on Scene
- Identify
other emergency units responding to this call.
- Response
Location
- Record
the location where your unit encountered the patient. Be as specific
as possible. For example
- record
the exact street address to which you responded
for a medical call
- names
of intersecting streets for vehicular accidents
- another
geographic location description, such as Memorial Park, for
a child with seizure.
- Zip Code
- Record
the zip code for the location to which you responded
- Inc Type
- Record
the type of incident encountered on this call: MCFRS-EMS
captures this information electronically - leave this section
blank.
- Occup
- Record
the occupancy type for the location you responded to for this call
local option.
MCFRS-EMS
captures this information electronically - leave this section
blank.
- Action
- Record
the actions data required by your jurisdiction.
MCFRS-EMS
captures this information electronically - leave this section
blank.
- Disp
- Record
the disposition of this call
MCFRS-EMS
captures this information electronically - leave this section
blank.
- Patient
Name
- Print
the patient’s last name, first name, middle initial.
- Parent/Guardian
- In
the case of a minor child, print the last name, first name, of the
child’s parent or legal guardian.
- Patient
Address
- Print
the patient’s residential address. Note that the residence
address may differ from the response location.
- Home Phone
- Print
the patient’s home phone number. Include the area code.
- Provider
1 ID Number: This
is the DFRS ID number of the CHARGE EMTB or ALS provider.
- Record
the unique alpha/numeric identifiers for the providers on this call.
Provider 1 should be the highest EMS certified member of the crew.
Record provider ID numbers using block style print (0,1,2,3,4,5,6,7,8,9).
- Provider
2 ID Number: If
any other crew members administer any portion of care to the patient,
they would be indicated as Provider 2 or Provider 3.
- Provider
3 ID Number:
If
any other crew members administer any portion of care to the patient,
they would be indicated as Provider 2 or Provider 3.
- Provider
1 Name
- Provider
2 Name
- Provider
3 Name
- Print
the provider’s names in the order that corresponds to the
Provider ID #’s.
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Seniors
