Snohomish County EMS/TC Council
Snohomish County EMS QA Submission

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Please share any compliments, questions, or concerns about Snhomish County EMS Providers. Thank you.

SUBMITTED BY

First Name:
Last Name:
Organization:
Contact Telephone:
Contact Email:

PATIENT INFORMATION

First Name Initial:
Last Name Initial:
Patient Age / Gender:
EMS patient report number if known:

HOSPITAL INFORMATION 

Hospital Record number if known:
Medical Record number if known:
Hospital Name

QUALITY ASSURANCE REPORT DETAILS

Incident Date:
Incident Location:
EMS Agency Involved:
Event Type:

NARRATIVE - WHAT HAPPENED

DESIRED OUTCOME OF QA PROCESS


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  • Snohomish County EMS/TC Council

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