HTML Preview Improvement Report page number 1.
COUNTY INVOLVED:
FRESNO KINGS MADERA TULARE
OTHER
OFFICIAL USE ONLY
CQI#
DATE RCVD:
Emergent
CONFIDENTIAL
(In accordance with California Civil Code Section 56, et seq, California Evidence Code Section 1040
and Section 1157, et seq, and California Code of Regulations, Title 22, Division 9)
Quality Improvement
Report
(Information for Attorneys representing the Central California EMS Agency)
Incident Logistics
Call Location: EMS Disp#:
Date: Time:
Location:
On Scene Enroute
At Hospital Other
Med. Record # or DOB:Patient Name:
PCR/BHRR# (Attach Copy):
Personnel Involved Agency Discussed with Individual
Yes No
Yes No
Yes No
Yes No
Yes
Yes No
Yes No
No
Primary Tracking
Date & time On-Duty Supervisor/PLN/PLO Notified:
Name & Title of Individual Contacted:
Author Information
Signature: Date:
Print Name: Cert #:
Agency/Facility: Date Submitted to PLO/PLN:
CENTRAL CALIFORNIA
EMERGENCY MEDICAL SERVICES
Non-Emergent