Contra Costa EMS
Event Reporting

Please use the online form below to pertinent information regarding the event - if you would prefer, you may download the EMS Event Reporting form and submit as directed on the form.

Questions about EMS Event Reporting? Please contact the EMS agency at 925-608-5454.

This information should originate from the provider involved and may be submitted anonymously. Please be advised that anonymous reporting may impact the ability to respond to your concern.

No patient names or other personal patient information should be reported on this form.

Reporting Party (do not complete for anonymous submission):

Name:

Title/Position:

Agency:

Phone:

Email:

Incident Information (complete as much information as is available):

Date of Incident:

Time of Incident:

Location of Incident:

Receiving Facility (if any):

Incident Number/PCR Number:

Incident Reported To:

Title/Position:

Please select all that apply to the issue you are reporting:

Exemplary Care (great job, unusual call)

Adverse Event (issue which may impact patient care)

Sentinel Event (issue which does impact patient care)

BLS Agency Treatment/Transport Issue (Epi administration, On-View, etc.)

Other

Details of Event:

Please provide a concise description of the event.

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Contra Costa EMS
Event Reporting

Reporting Party (do not complete for anonymous submission):

Incident Information (complete as much information as is available):

Please select all that apply to the issue you are reporting:

Details of Event:

Health Services Divisions

Contra Costa EMS Event Reporting

Reporting Party (do not complete for anonymous submission):

Incident Information (complete as much information as is available):

Please select all that apply to the issue you are reporting:

Details of Event:

Contra Costa EMS
Event Reporting