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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