Request For Incident Report Or Public Record - Pflugerville Fire Department

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PFLUGERVILLE FIRE DEPARTMENT

203 E. PECAN STREET PFLUGERVILLE, TEXAS 78660

Ph: (512) 251-2801

REQUEST FOR INCIDENT REPORT

PUBLIC RECORD

Instructions:

Provide the information requested in the boxes below. This information is required to verify the District's response to an

incident. This request must be presented along with the fee of $2.00 to process the report. No cash is accepted, the fee

must be paid by check, credit card or money order. Protected Health Information (PHI) will not be sent by e-mail.

THIS REQUEST IS FOR A COPY OF THE RUN SUMMARY REPORT PREPARED AFTER THE FIRE DEPARTMENT RESPONDS TO AN INCIDENT

Date of Incident:

Time of Incident:

PUBLIC RECORD

OTHER

FIRE

MEDICAL

Type of Incident:

Describe Other

Owner / Occupant / Patient Name:

Person(s) Involved

Address or Location of Incident:

All requests for PHI must be made in writing by the patient or the patient's designee (requires power of attorney). One form of identity

verification is required before any information will be released.

IF YOUR REQUEST IS FOR A PUBLIC RECORD, YOU MUST PROVIDE SPECIFIC INFORMATION

You must describe in detail what information you are requesting:

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

Name of Person Making Request:

Mailing Address:

Cell

Phone No.:

Address:

Phone:

Send Report to E-mail Address

Send Report to Mailing Address

Call When Ready for Pick Up

Date

Initial

Request Received: