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Use to report major medical incidents. Reference: FM 8-10-1.

LINE 1 -- DATE AND TIME______________________________(DTG)

LINE 2 -- UNIT________________________________________(Unit Making Report)

LINE 3 -- INCIDENT ___________________________________(DTG of Incident)

LINE 4 -- LOCATION___________________________________(UTM or Six-Digit Grid Coordinate With MGRS Grid Zone Designator) of Emergency)

LINE 5 -- EMERGENCY_________________________________(Specified Medical Emergency)

LINE 6 -- UNIT AFFECTED______________________________(Affected Friendly Unit)

LINE 7 -- NARRATIVE__________________________________(Free Text for Additional Information Required for Clarification of Report)

LINE 8 -- AUTHENTICATION____________________________(Report Authentication)