INSTRUCTIONS: Anyone with a comment or concern regarding patient care, patient management, crew interaction, safety, hospital staff interaction, public perception, or any other issue (positive or negative) related to one specific EMS activity may submit this form. Please provide as much information as possible so that appropriate supporting documents and personnel may be accessed as needed.

This confidential report is submitted to the CQI Committee and the agency/s involved in 2-3 days. If you feel the information is urgent in nature, please contact your immediate supervisor and/or the Medical Program Director, Dr. Marvin Wayne.

* 1. This report is initiated by:

* 2. Date of Incident

* required

* 3. Incident Identification

* 4. Medical Records Number (if available)

* 5. Emergency Department Triage Level (if applicable):

* 6. Agency or agencies involved: (check all that apply)

* 7. Agency or agencies involved: (check all that apply)

* 8. Was a person affected by the event?

* 9. Was your QA officer or immediate supervisor notified?

* 10. NARRATIVE - Please enter a factual description of the incident, and include statements made by persons involved in quotation marks. Please refrain from making judgments or offering opinions unless based on first-hand information.

* 11. Person/Agency Reporting: (Required)

* 12. I am requesting anonymity from the agency or agencies involved.

Thank you for completing this form. The information will be forwarded over a secure electronic connection to the agency/s involved within the next few business days.
If you do not receive a response in a timely manner, please call the WCEMSTCC office at (360) 715-6418.