McLean County Area EMS System Incident Report Form
This is a confidential form that is utilized to inform the EMS office of issues of concern relating to the provision of emergency medical care within the McLean County Area EMS System. This form is protected from disclosure under the Illinois Medical Studies Act.
Date of Incident *
MM
/
DD
/
YYYY
Date Report Filed *
MM
/
DD
/
YYYY
Reason For Report *
What is the Situation Related to *
Required
Situation: Describe the specific incident as objectively as possible *
Your answer
Background: Any pertinent information related to the situation
Your answer
Assessment: Why do you think this happened
Your answer
Recommendation: What can be done to improve the situation *
Your answer
Name of Individual Submitting Report *
Your answer
Email Address of Individual Submitting Report *
Your answer
Agency of Individual Submitting Report *
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