NOTE: This form is for use by healthcare and public safety personnel. Members of the general public or patients should use the 'Submit a Question or Complaint' form. ---- KCEMS EMS Incident Quality Assurance / Quality Improvement Report Form: This is a confidential professional standard review organization and/or quality assurance document of Kent County Emergency Medical Services, Inc. It is protected from disclosure pursuant to the provisions of Michigan law including: MCL 330.1143A, MCL 330.1748, MCL 331.531, MCL 331.532, MCL 331.20175, MCL 333.21513, MCL 333.21515 and all other applicable laws.
(Please include events surrounding, and contributing to, this incident)
Please upload a copy of the ePCR for reference. You may black out the Protected Health Information (PHI): name, address, DOB. etc.
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