EMS Feedback Request

Requester Information

Enter your agency and contact details so facility staff can follow up on your request.

Agency Required Start typing to find your EMS agency. Title or Position Required For example, paramedic, captain, supervisor, or QA/QI. Email Required Confirmation and follow-up messages are sent here. First Name Required Enter the requester's first name. Last Name Required Enter the requester's last name. Primary Phone Required Best direct number if the facility needs clarification. Secondary Phone Optional backup contact number.

Patient and Transport

Patient identifiers are used only to match the request with facility records.

Facility Arrival Date Defaults to today; adjust to the patient arrival date. Facility Arrival Time Approximate arrival time is acceptable. Patient First Name Optional, but helpful when available. Patient Last Name Optional, but improves record matching. Patient DOB Use MM/DD/YYYY, or leave blank if unknown. Age is calculated at arrival. Patient Age Required Enter an estimated age in whole years when DOB is unknown. Patient Sex Required Select the documented patient sex. Destination Hospital Required Facility where the patient was transported. MRN Optional. Add if provided by documenting RN or facility staff. Patient Type Required Broad patient category used to narrow diagnosis options. Patient Diagnosis Required Choose the closest diagnosis or request area. Patient Care Report Number Required PCR, incident, or run number from the EMS chart. Additional Comments Include the specific outcome details you need back from the facility.

Review and Submit

Confirm the request details before sending them to the destination facility.