Los Santos County
Emergency Medical Services
Please use this form to report any misconduct from any licensed prehospital EMS provider and send it to: Medical Review Board.
MISCONDUCT REPORT FORM
1.1. Reporting Persons Full Name:
1.2. Reporting Persons Phone Number:
1.3. Reporting Persons Address:
1.4. Reporting Persons Email Address:
1.5. Reporting Persons Agency (If applicable):
1.6. Comments/Statements:
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2.1. Reported Provider's Full Name(s):
2.2. Reported Provider's Badge Number(s):
2.3. Reported Provider's Agency:
2.4. Reported Provider's Designated Callsign:
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3.1. Type of Incident/Event:
3.2. Time & Location of Incident:
3.3. Detailed Description of Incident:
3.4. Name of Witnesses:
3.5. Evidence of Incident e.g. pictures:
3.6. ((Screenshots of Incident: ))
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Reporting an EMS provider may subject you to having your name revealed during an investigation, or when an investigation has been completed. Your report and the information inside may be passed to a Law Enforcement Agency or Department of Justice in the event of the report being criminal in nature, or when a false report is made on an EMS provider. Sending in a report to the EMS License Review Board automatically means that you acknowledge what has been written down in this disclaimer.
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Report EMS Misconduct
Please use this form to report any misconduct from any licensed prehospital EMS provider and send it to: Medical Review Board.
MISCONDUCT REPORT FORM
Section 1 - Reportee
spacer1.1. Reporting Persons Full Name:
1.2. Reporting Persons Phone Number:
1.3. Reporting Persons Address:
1.4. Reporting Persons Email Address:
1.5. Reporting Persons Agency (If applicable):
1.6. Comments/Statements:
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Section 2 - Reported Provider
spacer2.1. Reported Provider's Full Name(s):
2.2. Reported Provider's Badge Number(s):
2.3. Reported Provider's Agency:
2.4. Reported Provider's Designated Callsign:
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Section 3 - Incident Information
spacer3.1. Type of Incident/Event:
3.2. Time & Location of Incident:
3.3. Detailed Description of Incident:
3.4. Name of Witnesses:
3.5. Evidence of Incident e.g. pictures:
3.6. ((Screenshots of Incident: ))
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Section 4 - Disclaimer
spacerReporting an EMS provider may subject you to having your name revealed during an investigation, or when an investigation has been completed. Your report and the information inside may be passed to a Law Enforcement Agency or Department of Justice in the event of the report being criminal in nature, or when a false report is made on an EMS provider. Sending in a report to the EMS License Review Board automatically means that you acknowledge what has been written down in this disclaimer.
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Code: Select all
[divbox=white][center][img]https://cdn.discordapp.com/attachments/734847422014029850/1216150566334632106/3FBB7BBC-F226-424A-A907-7DBFC5243792_1.png?ex=65ff5779&is=65ece279&hm=7db724a92154e7db2eb93483e308f3d8e57831b696183b1b4554746ea05e60cc&[/img][/center]
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[center][size=200][color=black]MISCONDUCT REPORT FORM[/color][/size][/center]
[hr][/hr]
[divbox=darkblue][size=150][color=#FFFFFF][center]Section 1 - Reportee[/center][/color][/size][/divbox]
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1.1. Reporting Persons Full Name:
1.2. Reporting Persons Phone Number:
1.3. Reporting Persons Address:
1.4. Reporting Persons Email Address:
1.5. Reporting Persons Agency (If applicable):
1.6. Comments/Statements:
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[divbox=darkblue][size=150][color=#FFFFFF][center]Section 2 - Reported Provider[/center][/color][/size][/divbox]
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2.1. Reported Provider's Full Name(s):
2.2. Reported Provider's Badge Number(s):
2.3. Reported Provider's Agency:
2.4. Reported Provider's Designated Callsign:
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[divbox=darkblue][size=150][color=#FFFFFF][center]Section 3 - Incident Information[/center][/color][/size][/divbox]
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3.1. Type of Incident/Event:
3.2. Time & Location of Incident:
3.3. Detailed Description of Incident:
3.4. Name of Witnesses:
3.5. Evidence of Incident e.g. pictures:
3.6. ((Screenshots of Incident: ))
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[divbox=darkblue][size=150][color=#FFFFFF][center]Section 4 - Disclaimer[/center][/color][/size][/divbox]
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Reporting an EMS provider may subject you to having your name revealed during an investigation, or when an investigation has been completed. Your report and the information inside may be passed to a Law Enforcement Agency or Department of Justice in the event of the report being criminal in nature, or when a false report is made on an EMS provider. Sending in a report to the EMS License Review Board automatically means that you acknowledge what has been written down in this disclaimer.
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