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Emergency Medical Services Agency Unusual Occurrence Report Refer to The Back of This Form For Directions 1. Sanbenitoco. org/ems and can be electronically mailed. Thank you for taking the time to complete the Unusual Occurrence Form. All reports are prioritized and acted on accordingly. Completed Unusual Occurrence reports can be faxed to 831 636-4037 or Mailed to San Benito County Emergency Medical Services Agency 1111 San Felipe Road Suite 102 Hollister CA 95023 or A similar format of this form can be found on The EMS Agency s Website at www. Incident Date/Time 2. Provider Agency Name 3. Event 4. Reporting Date 5. Address or Location of Incident 6. Person Reporting Incident 7. Preferred Method of Contact Email Address 8. Phone 10. Fax 11. Affiliation 12. Unit 13. Type of Incident 14. Incident Description Be as specific as possible. Include names addresses times dates etc* Use separate sheets of paper if necessary. 15. Attachments YES / NO of pages or documents FOR EMS AGENCY USE EMS....

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An occurrence report is used to obtain the facts surrounding the incident in a timely manner and to preserve the evidence.

Filling Out an Effective Incident Report Include the full names of those involved and any witnesses, as well as any information you have about how, or if, they were affected. Add other relevant details, such as your immediate response—calling for help, for example, and notifying the patient's physician.

Incident Report Sample Walkthrough: A Step-by-Step Guide Step 1: Provide Fundamental Information. ... Step 2: Take Note of Any Damages and Injuries. ... Step 3: Identify Affected Individual(s) ... Step 4: Identify Witnesses and Take Their Statements. ... Step 5: Take Action. ... Step 6: Close Your Report.

State the specific date, day, time, and location of the incident. In addition to stating your presence and the presence of the person(s) involved directly in the event, state the names of any and all witnesses to the incident.

the names of any witnesses. the exact location and/or address of the incident. the exact time and date of the occurrence. a detailed and clear description of what exactly happened.

Incident reporting in healthcare refers to collecting healthcare incident data with the goal to improve patient safety and care quality. Done well, it identifies safety hazards and guides the development of interventions to mitigate risks, thereby reducing harm.

Effective Incident Reports identify the facts and observations. They avoid inclusion of personal biases; they do not draw conclusions/predictions, or place blame. Effective Incident Reports use specific, descriptive language and identified the action(s) taken by staff as a result of the unusual incident.

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232
Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
All Forms
Search all Forms
Industries
Forms in Spanish
Localized Forms
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232