Ambulance Dispatch Report

       North Dakota Department of Health
       Division of Emergency Medical Services
       600 E. Boulevard Ave. Dept. 301
       Bismarck, ND 58505-0200

Please complete this report and submit it to the North Dakota Department of Health when there has been an irregularity in the dispatch process for ambulance services. The Department of Health will use this information to better understand and improve the performance of the EMS system in North Dakota. Examples of irregularities include; non-response from an ambulance service, delayed response (30 minutes or more from time of dispatch to en route time), or any other reason that the dispatch process was unusual, confusing, or degraded.

Report Type: No ResponseDelayed ResponseOther (explain below)

Incident Date:

Incident Type: Trauma Medical Other

Nature of Call:

Ambulance Service Dispatched: Not Listed 5th Medical Group Ambulance Almont Ambulance Service Altru Health System Ambulance Service Ambulance Service, Inc. - Breckenridge Aneta Ambulance Service Ashley Ambulance Service Barnes County/City Ambulance Belcourt Ambulance Service Belfield Ambulance Service Inc. Berthold Ambulance Service Inc. Billings County Ambulance Service Bottineau Ambulance Service Bowbells Ambulance Service Bowdon Ambulance Service Bowman Ambulance Squad, Inc. Carpio Ambulance Service Carrington Health Center Ambulance Carson Ambulance Service Casselton Ambulance Service, Inc. Cavalier Ambulance Service, Inc. Community Ambulance Service Inc. - Beach Community Ambulance Service of New Rockford Community Ambulance Service Of Rolla Community Ambulance Service, Inc. - Minot Community Volunteer EMS of LaMoure Cooperstown Ambulance Service Dickinson Area Ambulance Service, Inc. Divide County Ambulance Service Drayton Volunteer Ambulance Association Inc. Edgeley Ambulance Service Edmore Volunteer Ambulance Service Ellendale Community Ambulance Service Emmons County Ambulance Service Esmond Community Ambulance Service Fessenden Ambulance Service Finley Ambulance Service First Medic Ambulance of Ransom County Flasher Ambulance Service F-M Ambulance Service, Inc. Gackle Ambulance Service Garrison - Max Ambulance District Glen Ullin Area Ambulance Service Glenburn Area Ambulance Service Inc Golden Heart EMS - Rugby Goodrich Ambulance Service Grenora Ambulance Service Halliday Ambulance Service Hankinson Vol Ambulance Service Harvey Ambulance Service, Inc. Hebron Ambulance Service Hillsboro Ambulance Service Hope Ambulance Service Hunter Ambulance Service Jamestown Area Ambulance Kenmare Ambulance Service Kidder County Ambulance Service Killdeer Area Ambulance Service Inc Kindred Area Ambulance Service Kulm Ambulance Corps, Inc. Lake Region Ambulance Service Lakota Ambulance Service Langdon Ambulance Service Lansford Ambulance Service Larimore Ambulance Service Inc. Leeds Ambulance Service Lemmon EMT Association Lidgerwood Rural ambulance Service District Maddock Ambulance Service Marmarth Ambulance Service Mcclusky Rural Ambulance District Mchenry Ambulance Service Mcintosh V.F.D. Ambulance Service Mckenzie County Ambulance Service Mcville Community Ambulance Service Medina Ambulance Service Mercer Co Amb Service Inc -- Hazen Mercer County Ambulance Service Inc. -- Beulah Metro Area Ambulance Service Inc Michigan Area Ambulance Service Inc. Minnewaukan Ambulance Service Mohall Ambulance Service Mott Ambulance Service Munich Rural Ambulance Napoleon Ambulance Service New England Ambulance Service New Leipzig Ambulance Service New Salem Ambulance Service New Town Community Amb. Service District Norman County EMS Northwood Ambulance Service Oakes Volunteer Ambulance Service Oliver County Ambulance Service Page Ambulance Service Park River Volunteer Ambulance Service Parshall Rural Ambulance Service Inc. Pembina Ambulance Service Plaza Ambulance Service Portal Ambulance Service Powers Lake Ambulance Association Ray Community Ambulance District Regent Ambulance Service Richardton-Taylor Ambulance Service Riverdale Ambulance Department Rock Lake Ambulance Service Rolette Ambulance Service, Inc Rugby Emergency Ambulance Service Ryder-Makoti Ambulance Service Sargent County Amb Service - Forman Sargent County Ambulance Service Sherwood Ambulance Service Spirit Lake Emergency Medical Service Standing Rock Ambulance Service Stanley Ambulance Service Tioga Ambulance Service Towner County Ambulance Service Inc. - Cando Towner Fire, Ambulance, and Rescue Service, Inc. Turtle Lake Ambulance Service Underwood Ambulance Service Upham Ambulance Service Valley Ambulance & Rescue Serv Inc Velva Ambulance Service Walhalla Ambulance Service Washburn Volunteer Ambulance Serv West River Ambulance Service West Traill Ambulance Service Westhope Ambulance Service Williston Ambulance Service Wilton Rural Ambulance Service Wing Rural Ambulance Wishek Ambulance Service Wyndmere-Barney Rural Amb Dist

Dispatch Time (military):

En route Time (military):

Was there another service dispatched? YesNo

If so, list second ambulance service dispatched. Not Listed 5th Medical Group Ambulance Almont Ambulance Service Altru Health System Ambulance Service Ambulance Service, Inc. - Breckenridge Aneta Ambulance Service Ashley Ambulance Service Barnes County/City Ambulance Belcourt Ambulance Service Belfield Ambulance Service Inc. Berthold Ambulance Service Inc. Billings County Ambulance Service Bottineau Ambulance Service Bowbells Ambulance Service Bowdon Ambulance Service Bowman Ambulance Squad, Inc. Carpio Ambulance Service Carrington Health Center Ambulance Carson Ambulance Service Casselton Ambulance Service, Inc. Cavalier Ambulance Service, Inc. Community Ambulance Service Inc. - Beach Community Ambulance Service of New Rockford Community Ambulance Service Of Rolla Community Ambulance Service, Inc. - Minot Community Volunteer EMS of LaMoure Cooperstown Ambulance Service Dickinson Area Ambulance Service, Inc. Divide County Ambulance Service Drayton Volunteer Ambulance Association Inc. Edgeley Ambulance Service Edmore Volunteer Ambulance Service Ellendale Community Ambulance Service Emmons County Ambulance Service Esmond Community Ambulance Service Fessenden Ambulance Service Finley Ambulance Service First Medic Ambulance of Ransom County Flasher Ambulance Service F-M Ambulance Service, Inc. Gackle Ambulance Service Garrison - Max Ambulance District Glen Ullin Area Ambulance Service Glenburn Area Ambulance Service Inc Golden Heart EMS - Rugby Goodrich Ambulance Service Grenora Ambulance Service Halliday Ambulance Service Hankinson Vol Ambulance Service Harvey Ambulance Service, Inc. Hebron Ambulance Service Hillsboro Ambulance Service Hope Ambulance Service Hunter Ambulance Service Jamestown Area Ambulance Kenmare Ambulance Service Kidder County Ambulance Service Killdeer Area Ambulance Service Inc Kindred Area Ambulance Service Kulm Ambulance Corps, Inc. Lake Region Ambulance Service Lakota Ambulance Service Langdon Ambulance Service Lansford Ambulance Service Larimore Ambulance Service Inc. Leeds Ambulance Service Lemmon EMT Association Lidgerwood Rural ambulance Service District Maddock Ambulance Service Marmarth Ambulance Service Mcclusky Rural Ambulance District Mchenry Ambulance Service Mcintosh V.F.D. Ambulance Service Mckenzie County Ambulance Service Mcville Community Ambulance Service Medina Ambulance Service Mercer Co Amb Service Inc -- Hazen Mercer County Ambulance Service Inc. -- Beulah Metro Area Ambulance Service Inc Michigan Area Ambulance Service Inc. Minnewaukan Ambulance Service Mohall Ambulance Service Mott Ambulance Service Munich Rural Ambulance Napoleon Ambulance Service New England Ambulance Service New Leipzig Ambulance Service New Salem Ambulance Service New Town Community Amb. Service District Norman County EMS Northwood Ambulance Service Oakes Volunteer Ambulance Service Oliver County Ambulance Service Page Ambulance Service Park River Volunteer Ambulance Service Parshall Rural Ambulance Service Inc. Pembina Ambulance Service Plaza Ambulance Service Portal Ambulance Service Powers Lake Ambulance Association Ray Community Ambulance District Regent Ambulance Service Richardton-Taylor Ambulance Service Riverdale Ambulance Department Rock Lake Ambulance Service Rolette Ambulance Service, Inc Rugby Emergency Ambulance Service Ryder-Makoti Ambulance Service Sargent County Amb Service - Forman Sargent County Ambulance Service Sherwood Ambulance Service Spirit Lake Emergency Medical Service Standing Rock Ambulance Service Stanley Ambulance Service Tioga Ambulance Service Towner County Ambulance Service Inc. - Cando Towner Fire, Ambulance, and Rescue Service, Inc. Turtle Lake Ambulance Service Underwood Ambulance Service Upham Ambulance Service Valley Ambulance & Rescue Serv Inc Velva Ambulance Service Walhalla Ambulance Service Washburn Volunteer Ambulance Serv West River Ambulance Service West Traill Ambulance Service Westhope Ambulance Service Williston Ambulance Service Wilton Rural Ambulance Service Wing Rural Ambulance Wishek Ambulance Service Wyndmere-Barney Rural Amb Dist

Second Ambulance Dispatch Time (military):

Second Ambulance En route Time (military):

Was the patient transported by an ambulance? YesNo

Please briefly describe what occurred (including any communication with the ambulance crew).

Submitted by:

Dispatch Agency:

Contact information for followup:

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