* 1. Date:

* 2. Name of Entity:

* 3. Person Completing Report:

* 4. Performance Improvement Criteria / Indicators
Number of occurrences scene time greater than 20 minutes this quarter.

* 5. Number of occurrences lift off time > 10 minutes from time mission accepted.

* 6. Explanation of above:

* 7. Number of missed flights this quarter.

* 8. Explanation of above:

* 9. Specific Occurrence Report
Age:

* 11. Chart Identification #:

* 12. Mechanism of Injury:

* 13. Identified injuries and pertinent information:

* 14. Patient Outcome:

* 15. Provider Discussion:

* 16. Contributing Factors

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