_  _  _  _  _  _  _  _  _  _  _  _  _  _  _  _  _  _  _  _  _  _  _ _  _  _  _  _  _ _  _  _  _  _  _ _  _  _  _  _  _
(Detach - Send with group going for help)

Request For Assistance

Name of victim:		Age:	
Notify:		Phone: (___)	
Date of incident:	Time:	
Nature of medical problem/symptoms:	

Conscious:	Yes	No
Breathing:	Yes	No

(Detach - Retain with patient)

Heartbeat:	Yes	No
Temperature: ________
First aid given:	
	
Cause of medical problem:	

Send out map marked with route to follow, location of victim,
evacuation sites, car key, coins for phones, and this form.

Instructions For Party Going For Help

Route to take:	
	
Location of vehicle:	
Description of vehicle:	
Where to drive:	

Call 911 or Operator and ask for Sheriffs Department.

Rescue party to:	___ Stay at trailhead
	___ Return to site of emergency

Patient Record

Questions for the first aid provider:

Is the site safe?	Yes	No
Is the victim safe from further injury?	Yes	No
Is the person conscious?	Yes	No
Is the person choking?	Yes	No
Is the person breathing?	Yes	No
Does the person have a heartbeat?	Yes	No
Is there sever bleeding?	Yes	No
    Where?	
Are there possible back or neck injuries?	Yes	No
Are there broken bones?	Yes	No
    Where?	
Is the person in severe shock?	Yes	No
Is there intense pain?	Yes	No
    Where?	
Does the person want assistance?	Yes	No
Does the person need outside help?	Yes	No
Does the person need/want evacuation?	Yes	No

Initial condition:	

Changes in condition:	

Patient’s name:	
Date and time of incident:	
Prepared by: