Medical Incident Review Form (MIR)

The purpose of this referral is to improve the quality and efficiency of patient care in the Peninsulas Emergency Medical Service Council, Inc. region. This form is intended to relay comments on any incident, positive or negative, regarding provision of EMS in the region. Submission of this document triggers further review of the specific incident. All information obtained through this process will remain confidential. This information will be used by the EMS agency and it’s Operational Medical Director (OMD) for the purposes of Quality Improvement (QI) to result in improved patient care.

Please provide as much of the requested information as possible.

This form may be submitted anonymously. However, if you would like us to contact you for additional information, we must have your contact information. All MIR information is confidential.

Section 1:  Referrer Contact Information
Phone Number:
Section 2:  Incident Details
Date of Incident:*
Call/PPCR Number:
Agency Involved:
AIC (If known):
Receiving Facility:*
Receiving Physician:
Section 3:  Reason for Review
Section 4:  Description of Events
Section 5:  Supporting Files
Document 1:
Document 2:
Document 3:

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