Safety Event Report
To support our Just Culture environment, individuals are encouraged to speak up when areas of improvement or concern are found. Reporting incidents involving safety concern should not be punitive; rather a way to improve and be a embrace a culture of learning and accountability.

When making a report, please know that you will be contacted for more details and discussion. An investigation will then be conducted by leadership, including Medical Direction to learn further details of the incident, how it impacted everyone involved, what we can learn and what can we improve.
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Report Date *
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DD
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YYYY
Incident Date *
MM
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DD
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YYYY
Reporting Agency/Department (If report is coming from outside of Lodi EMS)
Name of Reporter *
Patient Information *
Call Number (If applicable/available)
Brief Description of Care/Concern *
Submit
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