Alameda CountyEMS Event Reporting Form

Alameda County

EMS Event Reporting Form

This form is designed for use by individual clinicians, representatives from healthcare facilities, hospitals, EMS provider agencies, EMD communication centers, and coordinators within the Alameda County EMS system.

Reporting Party Information

Organization Name*

Please select your employer. We will contact you and your leadership team.

Select

First Name

Last Name

Phone Number

Phone

Email*

Confirmation will be sent to your email

Supervisor/Chief Notification Email (Recommended)

It is recommended to include your supervisor or chief's email address to ensure they receive timely notification of this event report submission

Additional Supervisor/Chief Notification Email (Recommended)

Anonymous Reporting

As anonymous submissions do not require contact information, follow-up information cannot be provided.

EMS Event Information

Incident Number

Incident Date

Category*

Select the best option; we may reassign if the event overlaps with multiple categories.

Clinical

Exceptional Patient Care

Operational

Suspected Human Trafficking

Event Details*

Please be clear and specific about what you're requesting to be reviewed. Provide an event summary, including any actions taken. Max of 4000 characters.

File Upload

Attach relevant documents if needed. Do not include protected health information (PHI), or personally identifiable information (PII), including patient names, or DOB.

Word, PDF, JPEG, PNG, EPS, SVG, TIFF, DOCX, XLSX, PPTX, ODT, ODP, ODS

Drag and drop files here or

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