Ems survey for calendar year 2015
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EMS SURVEY FOR CALENDAR YEAR 2015 Name of Service: ______________________________________________________________ Chief / Head of Service: _______________________________________________________ Mailing Address: _______________________________________________________________ Physical Address: ______________________________________________________________ Phone: __________________________________ Fax: _____________________________ Email: ______________________________________________ Name & Title of Person Completing Survey: Southeast Region EMS’ Survey Reporting Period: January 1 -December 31. 2015 This form is available online at www.serems.org This EMS survey will provide basic data about the EMS systems within SE Region. The data will be used for local, regional and statewide planning and evaluation; grant applications; improving training; other EMS program related aspects and funding requests. Both ground ambulance and first responder services are included in this survey. This survey is particularly important to help capture data from services who are not yet reporting to AURORA and to include first responder service data into our regional EMS response statistics. If you have any questions about AURORA, please contact: Todd McDowell (907) 465-8634, EMSdata@alaska.gov If your service is currently collecting prehospital data electronically, simply attach a summary report which contains the requested information for this form. 
Thank you for taking the time to complete this important survey. If you have any questions, please call Bobbi Leichty – 907-747-8005 To submit: Email Address: director@serems.org or Mail to: 100 Clothilde Bahovec Way Sitka, AK 99835 Submit this survev to our office by 9-19-16. Service Information Are you an Alaska Certified EMS Service? Yes No List the numbers of personnel you have in your service, their provider level, and if they are paid or volunteer. For "other" list all other personnel such as drivers, assistants, trained ETT and First Responders, etc.
Please check all types of communications used for emergency response by your service: Cell Phone _______ Telephone ________ Marine VHF ___________ VHF ___________ ALMR _____ Satellite Phone _______Sat phone number: ______________________ HAM radio: _______ Other – Please list: Does your agency have access to the internet? Yes No If yes, list the following information about your primary internet access: Location: _____________________ (e.g. EMS station, fire station, clinic, community center, squad member’s home, etc.). Internet Access Type: ____Satellite ____ Cable ____ DSL ____ Dial-up Access Speed, (answer “?” for unknown): ________ Upload ________ Download
Does your service fill out a pre-hospital patient care report (run sheet/PCR) for every patient you treat? Yes No (Region optional) If using electronic run sheet /PCR, what software are you using? __________________________________________________________________________ Do you provide a completed run sheet / PCR to the receiving provider or facility (clinic, hospital, medevac team)? Yes No Do you plan to participate in the AURORA EMS data system? Yes No Do need training in the AURORA EMS Data system? Yes No Does your agency routinely receive information on patient outcomes? Yes No Does your service do run reviews? Yes No If yes how often: _________ What is the emergency contact number or system in your community? 911 Other- please list ________________________________________ How do you call out your responders? ___________________________________ Does your service / group meet for EMS training? Yes No How often does your service / group meet for training? ______________________ Do you maintain responder training records? Yes No What training does your service have difficulty obtaining? CPR ____ ETT ____ ETT-EMT-1 Bridge __ EMT-1 EMT-2 _ EMT-3 _____ EMT Refresher _____ Pediatric _____ Continuing medical education / CME Medical Education _____ Other – please list:_______________________________________________________________________ __________________________________________________________________________________________ Patient Encounters How many times did your service respond to an EMS call, including patient care standbys, false alarms, refusals or cancelled runs, between January 1, 2015 December 31, 2015? Total number of responses __________ 2. How many EMS patients were evaluated, treated or transported by your service during 2015? Total number of patients: __________ Number of patients: Less than one year ___; 1 – 14 years ____ ; 15 and up ___ 3. Did your service submit data to AURORA for the full 2015 calendar year? Yes ___ No ___ (If yes, you do not need to fill out question 4. If you are currently collecting prehospital data electronically, simply attach a summary report which contains the requested information to this form.) 4. List the number of patient contacts by the patient's primary medical problem or injury below. List at least one per patient. Altered Level of Consciousness Abdominal Pain/problems Allergic Reaction Type if known Burns Cardiac Cardiac Arrest Chest Pain/Discomfort Cardiac – Other Please list: Diabetic Drowning/Near Drowning Suspected Drug/Substance use Suspected Alcohol use Frostbite Hypothermia OB Deceased – no treatment Suspected Poisoning Respiratory Respiratory Arrest Respiratory Distress Smoke Inhalation Respiratory Other Please list: Seizure Stroke Trauma General Illness Other – please list: AK RCD Approved 2-4-2015 Directory: wp-content -> uploads -> 2016 2016 -> 2017 afoCo Landmark Scholarship Program 2016 -> Instructions for the Preparation of Camera-Ready Contributions to the Conference Proceedings 2016 -> Step student Scholarships for Year 10-13 2016 -> The united church of canada 2016 -> Idan raichel biography – May 2016 Brief Producer, keyboardist, Lyricist, composer and Performer Idan Raichel 2016 -> An introduction to centre’s interventions expanding access to justice 2016 -> Sanchar Shakti 2016 -> Unit analysis should help here. We want number of bananas 2016 -> The Autobiography of Elder Joseph Bates 2016 -> The Great Heat and the Rhode Island Deep Water Bay Scallop (Argopecten irradians) Fishery 1875-1905 Download 111.49 Kb. Share with your friends:
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