Yolo County Emergency Medical Services Agency (YEMSA)

yemsa@yolocounty.org

137 N Cottonwood Street Woodland, CA 95695

530-666-8671

Section 1 of 1 in this document

EMS EVENT REPORTING FORM

An EMS Event is defined as any occurrence that has, or could potentially have, an impact—positive or negative—on patient care.

The purpose of this form is to provide individuals directly involved in a Yolo County EMS Event with an opportunity to share observations, concerns, suggestions, or commendations. Every submission is valued and will be reviewed, prioritized, and addressed appropriately to support continuous improvement and maintain high standards of care within the EMS system.

Incident Information: Please answer to the best of your ability.

Incident Date & Time:

Address/Location of Incident:

Provider Agency Name/Unit or Engine #:

Dispatch #:

PCR#:

Other Agencies On scene:

Receiving Facility:

Incident Description: Be as specific as possible. Include: names, address, times, etc.

Upload any attachments as needed or email them to YEMSA at emscqi@yolocounty.org

Click Here to Upload

Requested Action:

How would you like the investigation to be followed up on: Mark all that apply

After Action Report

Phone Call

Written

Meeting

Optional Reporter Information:

Providing your name and contact information is optional. If you choose to remain anonymous, please note that we will be unable to provide updates on the status of your report, and our ability to follow up or fully address your concern may be limited.

Person Reporting Incident:

Certification/License #:

Cell Phone #:

Employer/Affiliation:

I certify that all information on this form and uploaded documents, to the best of my knowledge, are true and correct.

First Name

Last Name

Choose how to sign

Draw Type