EMS Event Reporting Form

Any questions please contact:
Mike Schwenke Sarah Bush Lincoln EMS Coordinator
217-238-3612 or mschwenke@sblhs.org

Note: This form is for Quality Improvement only. All information is confidential.

* indicates a required field.

Date: *

Time: *

Agency/Person Involved: *

Person completing Event Report: *

Phone: *

Email: *

Please choose all that apply: *

Equipment of Vehicle Failure

Delay in Response or Transport

Injury to Patient or Damage to Property

Interfacility Transfer Issue

Policy/Protocol Deviation

Significant Exposure

Quality of Care

Other

Other:

Describe the incident below. Please include only the facts surrounding the incident. Do not include opinions of what happened or should have happened. *

Any questions please contact: Mike Schwenke Sarah Bush Lincoln EMS Coordinator 217-238-3612 or Email: mschwenke@sblhs.org

We respect and safeguard your privacy. This form is secure.

Community Wellness

Resources Directory

Health Styles Magazine

Health Styles Podcast

EMS Event Reporting Form

Resources Directory

Health Styles Magazine

Health Styles Podcast

EMS Event Reporting Form

Share Your Story