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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)