* 1. Date:

* 2. Name of Entity:

* 3. Person Completing Report:

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

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

* 6. Specific Occurrence Report
Age:

* 8. Chart Identification #:

* 9. Mechanism of Injury:

* 10. Identified injuries and pertinent information:

* 11. Patient Outcome:

* 12. Provider Discussion:

* 13. Contributing Factors

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