EMS Event Reporting Form

 

San Mateo County EMS Event Reporting

Please use this form to provide timely and pertinent information regarding an EMS event. The information submitted should originate from the provider(s) involved and may be submitted anonymously. Please note that anonymous reporting may impact the LEMSA's ability to respond to your concern. Please do NOT provide any protected health information (e.g., name, date of birth, or social security number of an EMS patient) with your submission. An EMS event number or date and address of the event will be sufficient. If you have questions or concerns, please contact the EMS Duty Officer through Public Safety Communications.

 
 
 
 
 
Phone
 

 

Incident information

Please complete as much information as possible.

 
 
 
 
 
 
 
 
 

Please refer to OPS 37 - EMS Event Reporting for detailed definitions of each category listed below:

 
 
 

Please upload any documentation necessary (i.e., photos, etc.)

Drop your files here
 

If you select yes, your identifiable information (e.g., name, email address, and phone number) will remain confidential and shall not be shared with any person or entity outside of the EMS Agency.