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* 1. Reporting Quarter

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* 2. Name of Entity:

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* 3. Person Completing Report:

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* 4. Performance Improvement Criteria / Indicators
Number of occurrences scene time greater than 20 minutes this quarter.

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* 5. Performance Improvement Criteria / Indicators
Number of occurrences greater than 30 minutes from dispatch to arrival on scene this quarter.

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* 6. Number of occurrences lift off time > 10 minutes from time mission accepted.

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* 7. Explanation of above:

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* 8. Number of missed flights this quarter.

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* 9. Explanation of above:

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* 10. For each patient above who was transferred out of TSA-D what was the determining diagnosis or factor that led to transfer out of TSA-D?

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* 11. Specific Occurrence Report
Age:

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* 12. Gender:

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* 13. Chart Identification #:

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* 14. Mechanism of Injury:

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* 15. Identified injuries and pertinent information:

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* 16. Patient Outcome:

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* 17. Provider Discussion:

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* 18. Contributing Factors

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