ANNEX A
INCIDENT REPORT FORM


File No. __________

(for office use only)
1.   Reporting Agency: 5.   Date of Incident: 
2.   Reporting Person:  6.   Time of Incident: 
3.   Telephone Number:  7.   Call originated from
phone #:
4.   Fax Number:  8.   Your email address:
9.   Emergency Service Providers involved: (If you type more than 2 lines, only the first 2 lines will appear on your printout)
10.   Public Safety Answering Point involved:

RCMP “J” Division

     Edmundston PSAP

Bathurst PSAP  

Miramichi PSAP              

Fredericton PSAP

     Saint John PSAP

Codiac PSAP

Unknown
11.  ESP Dispatcher involved:
12.  Members of the public involved: (If you type more than 3 lines, only the first 3 lines will appear on your printout)
13.  Description of the sequence of events: (If you type more than 5 lines, only the first 5 lines will appear on your printout)
14.  Possible causes resulting in or contributing to the incident:  (If you type more than 5 lines, only the first 5 lines will appear on your printout)

Note: Before hitting the "Submit Form" button, you should print a copy for your records 

If you can't submit this form electronically, please mail it to the following addresses with the priority going to the first one:

NB9-1-1 Service, Department of Public Safety, P.O. Box 6000, Fredericton, NB E3B 5H1 or fax to : 1-888-769-8833 NBAFC, 896 Chartersville Road Dieppe, NB E1A 1L1
or fax to: 1-506-859-7021