EMS Coordinator Communication Form

Please complete the below form or download it and email Sherri Kovach.

Please complete the EMS Coordinator Communication Form below

Purpose

What is the purpose for completing this form? *

Patient Follow-up Information: information requested for pre-hospital performance improvement

Communication: compliment, complaint, suggestion, other comments

Requestor Information

Name *

Title

Station

Unit Day *

Work Phone Number *

Work Email Address *

EMS Agency Information

Agency Name *

Agency Address *

EMS Coordinator Name *

Station

Unit Day *

Work Phone Number *

Work Fax Number *

Work Email Address *

Patient Follow-up Information

Patient information will be emailed to the EMS Performance Improvement Coordinator’s work email from Nationwide Children’s Secure Web Delivery System

Patient Name *

Date of Birth (Month/Year) *

Transport Date and Time *

Tranporting Unit Number *

Chief Complaint/Mechanism of Injury

Information Requested or Comments *

Note:

This document is confidential and subject to all applicable privileges under law, including but not limited to Sections 2305.24, 2305.25, 2305.251, and 2305.252 of the Ohio Revised Code. If you are not authorized to view or receive this information, please notify Sherri Kovach in the EMS Program at Nationwide Children’s Hospital immediately. Any unauthorized review, use, disclosure, distribution, copying, printing, or action taken in reliance on the contents of this document is strictly prohibited.

Nationwide Children's Hospital
700 Children's Drive Columbus, Ohio 43205 614.722.2000