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Bleeding Kit Resupply Request
Main Content
Bleeding Kit Resupply Request
First Hands Bleeding Control Kit Replacement Request
*
= Required Fields
Form Completion Date
Incident Date
*
Name
*
Officer Badge Number
Phone
E-mail
*
Agency Name
*
Mailing address to send replacement Bleeding Control Kit
*
Agency Category
Federal Agency
State Agency
County Agency
Municipal Agency
Private Agency - EMS
Private Agency - Non-EMS
Responder Category
Law Enforcement
Emergency Management
Emergency Medical Services
Fire Service - Paid
Fire Services - Volunteer
Communication (Dispatch)
Other
Bleeding Control Kit items used in the incident:
*
CAT - Combat Application Tourniquet
Trauma Sheers
Emergency Trauma Dressing 6"
Gloves
S-Rolled Gauze x 2
Other
In what county did you use the bleeding kit?
Did you utilize MS MED-COM during this incident?
Yes
No
Did you utilize the MSWIN radio system during this incident?
Yes
No
Did you utilize your personal cell phone during this incident?
Yes
No
Please give a description of the incident and how the kit was used.
*
Additional comments or recommendations
*