EMS Incident Report - Southern Nevada Health District

*Indicates a Required Field

*First Name		*Last Name
*Mailing Address
*City	*State	*ZIP Code
*Phone Number		*Email Address
EMS Incident Number(s)
*Date of Patient Care
*Address where the patient was picked up by the ambulance.
City	State	ZIP Code
*EMS Agency(s) Involved in Patient Care
EMS Agency Contact Person
Hospital Involved in Patient Care
Hospital Contact Person
Type of Concern
*Issues of Concern
This document and all correspondence surrounding it are part of the process to monitor, review, evaluate, and report on the necessity, quality, and level of care provided a patient and as such are confidential pursuant to NRS 49.265, NRS 450B.810 and NRS 629.061.

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