If the failure or malfunction of a device or piece of equipment is integral to or caused the EVENT, please fill in the following information:




EVENT is anonymous and reports cannot include identifying information regarding patient, provider or specific EMS service. No information will be retained regarding the specific incident related to the date, time, location or any information that may jeopardize the anonymity of the report or the privacy of the patient. Any submission that includes these identifiers will be deleted from the system completely and the report will not be included in the effort to improve the quality of the system of EMS care.

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