Book 35 - EMS Field Manual - LAFD Training

Section I: Field ProcedureslProtocols
MCI EMS REPORT SHORT FORM
The Multiple Casualty Incident (MCI) Short Form has been developed by the Los Angeles
County EMS Agency as an optional form for use by providers in situations where multiple
patients are encountered on scene. The form is a "shortened" version of the Los Angeles
County EMS form that encompasses the essential data for the incident while providing a
valuable timesaving tool to providers for multi-patient incidents. The MCI short form may
be used in place of the standard EMS Report Form in MCl's.
Page one Page one (back copy) Patient Release
When more than ten (10) patients are encounteredl the provider has the option of using the
MCI Short Form. When this form is usedl a standard EMS Report Form (F-902M) does not need
to be filled out. During a mass casualty incidentl the MCI Short Form can be used as a stand-
alone forml used along with a triage tagl or used in place of a triage tag (these options are at
the discretion of the department or provider). (Refer to Departmental Bulletin No. 04-1 9)
Each MCI EMS Report Short Form can accommodate up to four patients and is formatted in
quadruplicate. The back of the first page allows the patient to release the Fire Department from
liability. Use this section ONLY when patients that DO NOT meet the criteria of the LAFD
PRG or the LAFD Book 33, Ref. No. 808 * are released from the scene.
The fourth page has an adhesive backing and could be placed on the patient for tracking.
Once the patient is released from the scenel the patient can keep the adhesive copy for their
records. This adhesive copy can also be used as a record for the receiving facility! if the patient
seeks medical treatment on their own.
The MCI EMS Report Short Form will be carried by all companies and
will be included in the MCI packet.
* Patients who meet the above criterial require an EMS Report Form F-902M
completion and base hospital contact.
Revised: 512005 PAGE 2 OF 2