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CPER CAREReport Form

INSTRUCTIONS FOR USE

CareReports can be completed by Paramedics, Service Operators or others wishing to communicate with CPER's Quality Program. Please complete the form with as much detail as possible to provide context for full analysis.

Note: please do not include any patient health information (PHI) in your responses.

More Information

Name(*)
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Your Email
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EHS #
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Service
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Leave blank if none

Date of Call(*)
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Call #
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Communication Category
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Please describe
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Describe the nature of the event
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Characters remaining:

Attach a file
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If more that 500 words is required to describe the nature of the event please attach as a Word doc, PDF, or TXT file.

Verification
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If asked a verification question please click the images that match the description. If unsure click Reload and try again or click the headphones for an audio captcha.