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*