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Date:
Time:
PPCR#:
EMS Agency:
AIC:
Technician 2:
Technician 3:
Receiving Facility:
Receiving Physician:
Submitted By:
Email Address:
Reason for Review (Check appropriate boxes):
Unable to Establish Contact w/Medical Control:
Medical Control treatment needed but not performed:
Medical Control treatment initiated without physician order:
Regarding treatment orders from online Medical Control Physician:
Regarding EMS patient treatment or actions:
Summary:
Medical Control Incident