Alaska Car Seat/Child Passenger Safety

Pediatric EMS Transport Form

Dear Alaskan EMS Personnel, The Alaska Child Passenger Safety Partnership is collecting statewide Pediatric EMS Transport data. Your department may have already received one or more Safe Guard Pediatric Transport seats through generous funding from Alaska Highway Safety Office, Alaska Injury Prevention Center, and Safe Kids Alaska. We request that the following form be completed and submitted for each and every pediatric transport your department conducts, regardless of whether the Safe Guard seat is utilized. The form can be completed and submitted online, or printed and faxed to the Alaska Injury Prevention Center at (907)929-3940. The data and feedback collected will assist in determining if future funding for pediatric EMS transport products should be pursued. Thank you for your input!

Pediatric EMS Transport Report

* Enter the image text displayed above
* Department Name:
* Department Telephone Number:
* Submitted by:
* Date of Transport:	(MM/DD/YYYY)
* Age of patient:
* Approximate weight of patient:
* Nature of EMS response:
If "other", please describe:
* Response Site:
If "other", please describe:
* Transport restraint mode selected:
If "other", please describe:
Comments: