TEMS Hospital Re-Stocking Incident Report

PURPOSE: This form allows the TEMS Staff a means of tracking incidents regarding the exchange of essential emergency medical supplies on regional EMS ambulances through a one-for-one exchange system with area hospital emergency departments and hospital pharmacies.

Name / Title of Person Reporting:    

Agency / Hospital of Reporting Person:    

Hospital Where Exchange Occurred/Incident Occurred:

Phone:       E-Mail: 

Date of Incident:         example 01/01/03  

EMS Agency Attempting to Exchange:   

EMS Unit Attempting to Exchange:

This area should be used to describe the problem, observation or inability to perform an exchange

at the facility or by the EMS agency (Please list items attempting to exchange for re-stock purposes):