Scene Call of the Year Award Application

If you would like to complete and submit this form for consideration, please keep in mind that the following criteria will be used to evaluate Scene Call of the Year Award Applications:

♦  Scene safety

♦  Triage decisions

♦  Complex planning & accident scene management

♦  Integration of the helicopter into the call

♦  Use of skills that went beyond the "call of duty" to treat the patient

Name of Department: 

Date of Call: 

Location of Accident:   

Dispatch information you were given:   

What you found on arrival:   

Describe your operation at the scene:   

What made this rescue/ambulance call unique from others you have completed?   

What did this call teach you? 

Did personnel treating this patient use personal protective eyewear (PPE)?  Yes No

List Duty Crew:   

List Mutual Aid departments (include law enforcement and dispatch personnel):   

Name and Title of person completing this application: 

Today's date: 

Chief's Name: 

If available, (not required), include any photographs, slides, videotapes or news articles of the incident. (E-mail to kmitchell@mrmcffl.org or mail to Flight For Life, Attn: Kathy Mitchell, 2661 Aviation Road, Waukesha, WI  53188)

I am forwarding photos:  Yes No

Thank you for submitting your application!

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