Fillable Santa Cruz County EMS Agency (HSA)

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Santa Cruz County EMS Agency (HSA)

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EMERGENCY MEDICAL SERVICES DIVISION
David Ghilarducci, MD FACEP FAEMS
Medical Director
UNUSUAL OCCURRENCE REPORT
Completed Unusual Occurrence Reports can be emailed to brenda.brenner@santacruzcounty.us or FAXED to 831-454-4488
Incident Date/Time:
Provider Agency Name:
Event #
Reporting Date:
Address or Location of Incident:
Person Reporting Incident and Title:
Preferred Method of Contact:
Email: Phone:
Unit #
Type of Incident:
Incident Description: Be as specific as possible. Include names, addresses, times, dates, etc. Use Page 2 and/or a separate
sheets of paper if necessary.
Attachments: YES NO # of additional pages or documents
FOR EMS AGENCY USE
Final Disposition:
Reviewed By:
Date received:
Date closed:
Santa Cruz County EMS Agency
Case Number:
UNUSUAL OCCURRENCE REPORT PAGE 2
Incident Date/Time:
Provider Agency Name:
Event #
Reporting Date:
Person Reporting Incident and Title:
Incident Description: Be as specific as possible. Include names, addresses, times, dates, etc. Use separate sheets of paper if
necessary.
Attachments: ____YES ____NO ____# of additional pages or documents
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Santa Cruz County EMS Agency (HSA)

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Completed 21 February 2021

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