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EMS Region where event occurred
 

Year:            Quarter:    
Individual Reporting Event:
 
Type of Event:   Please choose the classification that best describes the event.
 
Result of Event:   In your opinion, please estimate the possible impact of this safety event.
 
Category of Event:   Please choose the part of the ambulance call during which the safety event occurred.
 
Safety event description:   Please describe the safety event in the space provided. Provide your opinion as to the cause of the safety event and any suggestions to prevent another similar event. This is an anonymous reporting system. Do not include any information that will identify the EMS practitioner, EMS service, location of the event or date of the event in this space. Please be specific in describing the event and possible causes. Include equipment brand names, names of involved drugs, and other specifics to assist the review committee in identifying the cause of the safety event. You are also encouraged to include suggestions that may reduce the chance of a recurrence of this event.
 
    

Commonwealth of Pennsylvania Department of Health
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