1. Incident Information

 
33% of survey complete.
Use this ResQCPR and/or Respiratory Compromise Report form to submit the details of all King tube or IGEL attempts and CPR performance. This does not replace the MIR. It is for data collection and quality assurance purposes only. Questions marked with an asterisk * must have an answer, or you will not be allowed to proceed. After completing page 1, you may SKIP to the appropriate page to complete your report.
Questions related to CPR and AED/PAD use are on page 2.
Questions related to BLS placement of the King tube or IGEL are on page 3.

Please contact the Quality Assurance Coordinator of the CQI Committee if you have any questions. Thank you.

Incident date

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* 1. Incident date

FD incident number

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* 2. FD incident number

District/agency AND station number

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* 3. District/agency AND station number

Name of provider completing report

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* 4. Name of provider completing report

Phone # of provider if additional information is needed

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* 5. Phone # of provider if additional information is needed

Patient Sex:

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* 6. Patient Sex:

Patient age (est.) or date of birth

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* 7. Patient age (est.) or date of birth

Patient condition: (check all that apply)

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* 8. Patient condition: (check all that apply)

Patient outcome (check all that apply)

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* 9. Patient outcome (check all that apply)

Narrative (Complete this section in order to document the circumstances of the intervention, note any problems, and/or to include other information relevant to data collection for educational, statistical, and quality assurance purposes)

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* 10. Narrative (Complete this section in order to document the circumstances of the intervention, note any problems, and/or to include other information relevant to data collection for educational, statistical, and quality assurance purposes)

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