Staging environment
— Use synthetic patient details. All notifications go to the internal test inbox.
EMS Feedback Request
1
Requester
2
Patient
3
Review
Requester
Agency
Required
Request a missing agency
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First Name
Required
Last Name
Required
Email
Required
Title or Position
Required
Primary Phone
Required
Secondary Phone
Patient & Transport
Facility Arrival Date
Defaults to today; adjust to the patient arrival date.
Facility Arrival Time
Central Time (CST/CDT). Approximate time is acceptable.
Patient First Name
Patient Last Name
Patient DOB
Leave blank if unknown.
Patient Age
Required
Estimate in whole years if DOB is unknown.
Patient Sex
Required
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Destination Hospital
Required
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MRN
Patient Type
Required
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Patient Diagnosis
Required
Select patient type first
Patient Care Report (PCR) Number
Required
Additional Comments
Review and Submit
Request Agency Addition
Close
Agency Details
Agency Name
Required
Agency Address
Required
Agency Phone
Required
Your Email
Required
Feedback Recipient
Contact Name
Required
This is usually an administrator, EMS chief, QA/QI lead, or other leadership contact.
Role or Title
Required
Contact Email
Required
Contact Phone
Agency request sent
STRAC support will review the agency details.
