TECC Equipment Use-Reporting Form You must have JavaScript enabled to use this form. Agency Agency - Select -Alexandria, City of - Fire/EMSAlexandria, City of - Police DepartmentArlington County - Fire/EMSArlington County - Police DepartmentDumfries, Town of - Police DepartmentFairfax, City of - Fire/EMSFairfax, City of - Police DepartmentFairfax County - Fire/EMSFairfax County - Police DepartmentFalls Church, City of - Police DepartmentFauquier County - Fire/EMSFauquier County - Sheriff's OfficeHaymarket, Town of - Police DepartmentHerndon, Town of - Police DepartmentLeesburg, Town of - Police DepartmentLoudoun County - Fire/EMSLoudoun County - Sheriff's OfficeManassas, City of - Fire/EMSManassas, City of - Police DepartmentManassas Park, City of - Fire/EMSManassas Park, City of - Police DepartmentMiddleburg, Town of - Police DepartmentOccoquan, Town of - Police DepartmentPrince William County - Fire/EMSPrince William County - Police DepartmentPurcellville, Town of - Police DepartmentStafford County - Fire/EMSStafford County - Sheriff's OfficeQuantico, Marine Corps Base - Fire/EMSQuantico, Town of - Police DepartmentVienna, Town of - Police DepartmentMWAA - Police DepartmentArlington County - SheriffGeorge Mason University - Police DepartmentNOVA Community CollegeOther… Enter other… Name Email Phone Incident Date Incident Time Incident number (if known) Incident Jurisdiction - None -Arlington CountyAlexandria, City ofClifton, Town ofDumfries, Town ofFairfax, City ofFairfax CountyFalls Church, City ofFauquier CountyHamilton, Town ofHaymarket, Town ofHerndon, Town ofHillsboro, Town ofLeesburg, Town ofLoudoun CountyLovettsville, Town ofManassas, City ofManassas Park, City ofMiddleburg, Town ofOccoquan, Town ofPrince William CountyPurcellville, Town ofQuantico, Town ofRound Hill, Town ofStafford CountyVienna, Town of Patient Type - Select -Civilian/CitizenFirst Responder (Fire/EMS)First Responder (Law Enforcement) Was the patient transported to a hospital? - Select -YesNo Hospital Hospital - None -Children's National HospitalGeorge Washington University HospitalFauquier HospitalInova Alexandria HospitalInova Emergency Care Center Springfield HealthplexInova Emergency Care Center - CornwallInova Emergency Care Center-FairfaxInova Emergency Care Center-RestonInova Fair Oaks HospitalInova Fairfax HospitalInova Healthplex - LortonInova Healthplex-AshburnInova Loudoun HospitalInova Mount Vernon HospitalMary Washington Healthcare ED at Lee's HillMary Washington HospitalMedstar Georgetown University HospitalNovant Haymarket Medical CenterReston Hospital CenterSentara Lake RidgeSentara Northern Virginia Medical CenterSpotsylvania Regional Medical CenterStafford HospitalStoneSprings Hospital CenterUVA Prince William Medical CenterVirginia Hospital CenterWashington Hospital CenterOther… Enter other… Transport Agency & Unit # (if known) Mechanism of injury? Was the treatment applied correctly? - Select -YesNoUnsure Was the treatment effective? - Select -YesNoUnsure Was NVERS/UASI-funded equipment used? - Select -YesNoUnsure TECC Equipment Used MET Tourniquet Other Tourniquet Celox Rapid Other hemostatic agent Wound packing gauze (non-hemostatic) Elastic bandage (ace wrap) Commercial pressure bandage Chest seal Chest decompression needle Other… Enter other… CAPTCHA Submit Leave this field blank
