Yolo County Emergency Medical Services Agency (YEMSA)

yemsa@yolocounty.org

137 N Cottonwood Street Woodland, CA 95695

530-666-8671

EMS EVENT REPORTING FORM

EMS Event is defined as: Any event deemed to have impact or potential impact on patient care, either positive or negative. The purpose of this form is to give any person directly involved with a Yolo County EMS Event an opportunity to share comments, concerns, suggestions and recognition. All EMS Events reported will be, prioritized, investigated, and acted on accordingly.

Incident Information: Please answer to the best of your ability.

Incident Date & Time:

Address/Location of Incident:

Provider Agency Name/Unit or Engine #:

Dispatch #:

PCR#:

Other Agencies On scene:

Receiving Facility:

Incident Description: Be as specific as possible. Include: names, address, times, etc.

Upload any attachments as needed or email them to YEMSA at emscqi@yolocounty.org

Click Here to Upload

Requested Action:

How would you like the investigation to be followed up on: Mark all that apply

After Action Report

Phone Call

Written

Meeting

Reporter Information:

The reporter information may be left blank if the reporting party wants to remain anonymous. Please keep in mind that if the reporting party chooses to remain anonymous, a status of the report cannot be given and it will impact the ability to respond to your concern.

Person Reporting Incident:

Certification/License #:

Cell Phone #:

Employer/Affiliation:

I certify that all information on this form and uploaded documents, to the best of my knowledge, are true and correct.

First Name

Last Name

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