REGIONAL AIR AMBULANCE
QUALITY IMPROVEMENT SCREENING FORM

Run Date and Number:
Requesting Agency:
Time of Request:
Location of Call:
Responding Air Medical Unit:
Transport To:

 

Primary Issues:
Inaccurate ETA:
Transmission Problems with Rad:
Aircraft had Difficulty Findin:
Clinical Issues:
Clinical Issues Details:
Scene Time More than 30 Mins:
No Issues With Request:

 

Secondary Issues:

LZ Hazards:
Equipment Failure:
Equipment Failure Details:
Combative Patient:
Aircraft Hazards:
Restraints Used:
Ground Ambulance Crew Names:
Comments:
Dispatch Center Comments:
Flight Service Representative Comments:
Regional Review -
Actions and Recommendations:

 

COMPLETED FORM SHOULD BE RETURNED TO SAEMS OFFICE
WITHIN 24 HOURS OF REQUEST FOR SERVICE.

Fax form to: 520-529-2369 (download .PDF file) or
Complete on Webpage (www.saems.net)

Effective 10/2007

 

For more information, contact Taylor Payson, Executive Director.
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