SAEMS REGIONAL AIR AMBULANCE QUALITY IMPROVEMENT SCREENING FORM
Please submit within 24 hours of request for Air Ambulance
Run Date
Time of request
ETA Given
Actual Arrival Time
Requesting Agency
Responding Air Agency
Location of Call
Date Report Sunbmitted
Submitted By
Email Address
Primary Issues
No Issues
Inaccurate ETA
Communication Issues - Meds Control
Communication Issues - Radio Frequency
Landing Zone Issues
Scene Time >30 Minutes
Safety Issues
LZ Hazards
Combative Patient
Restraints Used
PT RSI'D
Equipment Failure
Aircraft Issues
GROUND AMBULANCE CREW CONTACT INFO AND COMMENTS
DISPATCH CENTER CONTACT INFO AND COMMENTS
AIR MEDICAL REP CONTACT INFO AND COMMENTS
Indicates Response Required
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