S-SV EMS Agency
Sierra-Sacramento Valley EMS Agency
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Table of Contents
100 – State Law & Regulation
200 – Local EMS Agency (LEMSA)
300 – Hospitals
400 – Provider Agencies
500 – Patient Destination
600 – Documentation & QI
700 – Equipment & Supplies
800 – Field Policies & Treatment Protocols
900 – EMS Personnel
1000 – Training Programs
1100 – Procedure Policies
Protocols (ALS/BLS)
Cardiovascular (ALS/BLS)
Respiratory (ALS/BLS)
Medical (ALS/BLS)
Neurological (ALS/BLS)
OB/GYN (ALS/BLS)
Environmental (ALS/BLS)
Trauma (ALS/BLS)
Pediatric (ALS/BLS) Protocols
Protocols (LALS)
Cardiovascular (LALS)
Respiratory (LALS)
Medical (LALS)
Neurological (LALS)
OB/GYN (LALS)
Environmental (LALS)
Trauma (LALS)
Pediatric (LALS) Protocols
HPP
BLS Optional Skills Report
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-
Step
1
of 2
Instructions
Please complete all pertinent sections of the form, and click the 'Submit' button at the bottom of the second page to submit the report to S-SV EMS. Note: Additional data fields may show depending on your responses to certain questions.
Provider Agency Name
*
Reporting Party Name
*
Incident Date
*
Incident #
*
Incident Address
*
Address Line 1
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Patient Gender
Patient Age
Patient Weight
Contact email (if you want an email copy of the completed form)
Would you like to send a copy of the completed form to additional email addresses?
Yes
No
Additional recipient email address #1
Additional recipient email address #2
Next
Option Skill Utilized
*
i-gel
Naloxone
Epinephrine
Attempts
1
2
3
Placement Successful?
Yes
No
Lung Sounds Confirmation
Yes
No
ETCO2 Confirmation
Yes
No
i-gel Size
3
4
5
Complications
Yes
No
Describe Complications
Dose
Route
Auto-Injector
IM Injection
Complications
Yes
No
Describe Complications
Dose
Complications
Yes
No
Describe Complications
Form submission date & time
*
Date
Time
Submit