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Get NY DOH-4461 2016-2024

Eing reported. Copy additional pages as needed. 1. Please attach copies of any agency specific Incident Reports. 2. Page 2 is for general information relating to the incident only and must be completed for all reporting. 3. Section 1 must be completed if a patient is injured or dies as a result of EMS involvement. 4. Section 2 must be completed for a motor vehicle crash involving death or injury to a patient, member of the crew or other person which requires hospitalization or care by a physicia.

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