EMS Event Reporting Form

Any questions please contact:
Mike Schwenke Sarah Bush Lincoln EMS Coordinator
217-238-3612 or [email protected]

Note: This form is for Quality Improvement only. All information is confidential.

* indicates a required field.

Date: *

Time: *

Agency/Person Involved: *

Person completing Event Report: *

Phone: *

Email: *

Please choose all that apply: *

Equipment of Vehicle Failure

Delay in Response or Transport

Injury to Patient or Damage to Property

Interfacility Transfer Issue

Policy/Protocol Deviation

Significant Exposure

Quality of Care

Other

Other:

Describe the incident below. Please include only the facts surrounding the incident. Do not include opinions of what happened or should have happened. *

Any questions please contact: Mike Schwenke Sarah Bush Lincoln EMS Coordinator 217-238-3612 or Email: [email protected]

We respect and safeguard your privacy. This form is secure.

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EMS Event Reporting Form

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EMS Event Reporting Form

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