HomeMy WebLinkAboutunusual-occurrence-form-170531aAlameda County EMS Agency Unusual Occurrence Form All of the following information must be documented on this form
This form may be completed electronically - ‘tab’ through the fields.
When completed, click "Email" above, to send form to EMS. PCR attached
Date of Occurrence: ___________ Time: _______ Patient ID: __________________________________
Location: ____________________ Unit #: _______ CMED/Agency Incident # : ______________________
Form completed by: Name: ______________________ Title: _______________ Agency: _____________
Other(s) involved (include name, title and agency):
Witness(es) (persons familiar with incident; include
name, title, department, relationship):
Nature of Occurrence
1. Check all appropriate boxes 2. Attach PCR
If yes, contact the EMS Medical Director at (510) 618-2042
Specific issue _______________________________________________________________________
Details of Occurrence
Immediate efforts to resolve this issue:
TREND REPORT INFORMATION:
Affecting
Not Affecting
Revised 05-31-17 *See reverse
*Threat to Public Safety as defined by Health and Safety Code 1798.200
Any of the following actions shall be considered evidence of a threat to public health and safety and
may result in the denial, suspension or revocation of a certificate or license issued under this division
or in the placement on probation of a certificate or license holder under this division.
1.Fraud in the procurement of any certificate or license under this division
2.Gross negligence
3.Repeated negligent acts
4. Incompetence
5.The commission of any fraudulent, dishonest or corrupt act related to the qualification,
functions and duties of pre hospital personnel
6.Conviction of any crime which is substantially related to qualification, functions and duties of
pre hospital personnel
7.Violating or attempting to violate directly or indirectly any provision of this division
8.Violating or attempting to violate federal or state statute or regulation which regulates
narcotics, dangerous drugs or controlled substances
9.Addiction to the excessive use of or the misuse of alcohol beverages, narcotics, dangerous
drugs or controlled substances
10.Functioning outside the supervision of medical control in the field care system operating at thelocal level, except as authorized by any other license or certification
11.Demonstration of irrational behavior or occurrence of a physical disability to the extent that a
reasonable and prudent person would have reasonable cause to believe that the ability to
perform the duties normally expected may be impaired
12.Patient Maltreatment: verbal or physical occurrence identified which harm, insult, neglect orabuse the patient.
13.Controlled Substance: Loss/ broken narcotic vials / defective /Incorrect counts