1. Incident Information

 
50% of survey complete.
The Anaphylaxis Treatment Report (Epinephrine administration by BLS) 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. If CPR or a King tube airway procedure was initiated/attempted on this incident, you must complete the CPR/King tube online form to report these interventions. Please contact the Quality Assurance Coordinator of the CQI Committee if you have any questions. Thank you.

* 1. Incident date

* 2. FD incident number

* 3. District/agency AND station number

* 4. Name of provider completing report

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

* 6. Patient Sex:

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

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

* 9. Patient outcome (check all that apply)
(Note: Per Whatcom County protocol, any patient who receives Epinephrine (pre- or post-EMS arrival) should be transported to the ED, preferably by ALS.

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