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* 1. Date:

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* 2. Name of Entity:

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* 3. Person Completing Report:

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* 4. Performance Improvement Criteria / Indicators
Number of trauma-related patients pronounced dead on scene this quarter.

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* 5. Number of occurrences of prolonged wait times for EMS provider response to scene this quarter.

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* 6. Specific Occurrence Report
Age:

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* 7. Gender:

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* 8. Chart Identification #:

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* 9. Mechanism of Injury:

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* 10. Identified injuries and pertinent information:

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* 11. Patient Outcome:

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* 12. Provider Discussion:

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* 13. Contributing Factors

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