Issuu on Google+

Dundalk Units & Branch Please take a minute to read this form to aid us providing your service Contact Name: ______________________________________________________________ Organisation ________________________________________________________________ Address for Reference: ________________________________________________________ E-Mail Address: _____________________________________________________________ Telephone Numbers: Mobile: ___________________

Fixed Line: _________________

Backup Contact: Name: ________________________

Tel: _______________________

Event Details Event Date: _________________________________________________________________ Location of Event: ___________________________________________________________ Type of Cover: (please tick) Ambulance Crews: 1 2 3 Off-Road 4x4: 1 Patient Transfer: Minibus 1 Field Crews: No. _________ Relevant Information: ________________________________________________________ __________________________________________________________________________ Crew On-Site Time: _________________________________________________________ Estimated Finishing Time: ____________________________________________________ Number Attending Event: _____________________________________________________ (An estimated No. will suffice, health & safety requirements may affect crews required.) Due to our geographical location, we can transfer patients to Emergency Departments in both Southern and Northern Hospitals. If you have participants with Northern Ireland Hospital requirements please tick: __________ Please indicate if other services will be in attendance: Gardai: _____ HSE Ambulance: _____ Fire Service: _______ Other: ___________________________________________________________________________ ___________________________________________________________________________


request