New Jersey Department of Health

Office of Emergency Medical Services

PO Box 360

Trenton, NJ 08625-0360

609-633-7777 (Phone) 609-633-7954 (Fax)	Quarterly Report for

BASIC LIFE SUPPORT AMBULANCES

PROVIDING EMERGENCY RESPONSE
Reports are due to Office of Emergency Medical Services by the 30th of April, July, October and January.

Reporting Quarter (Check only one)

1st 2nd 3rd 4th	Year

20

Service Name

Telephone Number

Street Address

Fax Number

City, State, Zip Code

BLS Charge Per Call

Name of Person Completing Report

Name of EMS Director

Section 1 – Call Totals
1	Total Dispatches
Comments:

2	Calls with Patients	(3 + 4 + 5) (
3	D.O.A.
4	R.M.A.
5	Treat and Transport
Section 2 – Patient Age / Sex Breakdown
Age Range (Years)
Sex
0 – 1 Year
Male
2 – 8 Years
Female
9 – 20 Years
Unknown
21 – 45 Years
Total Patients (

(Section 1, #2)
46 – 65 Years
66 Years and older
Unknown
Total for All Ages (Section 1, #2)(
Section 3 – Nature of Call
Total Medical
Total Trauma
Allergic Reaction
Aircraft Crash
Behavioral
Bicycle Crash
Cardiac Arrest
Blunt Trauma
Cardiac (Other)
Burns
Diabetic
Fall
Drowning / Near Drowning
Firearm
Environmental (Heat/Cold)
Machinery
GI Complaint
Motor Vehicle Crash
Neurological (CVA/Stroke)
Pedestrian – M.V.C.
OB / GYN
Sexual Assault
Poisoning / Overdose
Stabbing
Respiratory
Watercraft Crash:
Seizures
Other:
Weakness/Malaise/Fever	DOA = __________ (Section 1, #3)

Medical Total+Trauma Total+DOA = __________ (Section 1, #2)
Unconscious / Syncope
Other
Program Name

Reporting Quarter (Check only one)

1st 2nd 3rd 4th	Year

20
Section 4 – Procedures
Assist with Inhaler
Bleeding Control
Assist with Epinephrine
Neonatal Delivery
Assist with Nitroglycerine
Spinal Immobilization

(Collar, CID, Longboard, KED)
Oral / Nasal pharyngeal Airway
Advanced Airway (Combitube or LMA)
SAED
Suctioning
Traction Splint
Honored a D.N.R.
Section 5 – Destinations
Hospital Name	Hospital Number	Number of Patients Transported
Total Patients Transported (Section 1, #5) (

Quarterly Report for

Basic Life Support Ambulances Providing Emergency Response

(Continued)

EMS-26

AUG 12	Page 2 of 2 Pages.

AUG 12	Page 1 of 2 Pages.

EMS-26, Basic Life Support Quarterly Report

EMS-26, EMS, basic life support, BLS, quarterly report, ambulance, emergency medical services

EWhite

2005-11-14

NJDOH