Emergency First Response

Responders in Action Online Report Form

* Required Field

* Responder’s Name:

* Address:

* City:

* State/Province:

* Zip/Postal Code:

* Country:

* Phone:

* Email Address:

* Date of your last Emergency First Response Certification/Recertification Course:

Name of your EFR Instructor/Trainer:

EFR Instructor/Trainer No.:

* Description of Events

* Location of Incident:

* Date of Incident:

* Please describe the incident, including the nature of the injury or illness, the skills used to render aid,
and if possible, information on the outcome.

By marking this box I understand I am granting Emergency First Response Corp. permission to reprint the details of this incident for the benefit of other Responders. I understand information that may identify the patient will be omitted but my name as an Emergency Responder may be used.

When submitting a report form to recognize another person for using their skills, please provide your contact information.

Name:

Address:

City:

State/Province:

Zip/Postal Code:

Country:

Email Address:

Phone:

If applicable, your EFR Instructor No.:

Please return certificate to:

Me Responder

*** Please select your country before submitting the form ***