Get the free PreHospital Save Nomination Form - WMEMS

PreHospital Save Nomination Form Region 1 Western Massachusetts Emergency Medical Services, Inc. Section 1 (Please print name as you wish it to appear on award certificate). Names of all responders

How to fill out prehospital save nomination form

How to fill out prehospital save nomination form:

1. Start by carefully reading the instructions provided on the form. This will give you an understanding of what information is required and how to fill out the form correctly.
2. Begin by providing your personal details such as your name, contact information, and any relevant identification numbers or codes.
3. Fill out the section requesting details about the patient who received prehospital care. Include their name, age, gender, and any other identifying information.
4. Specify the date and time of the incident when the prehospital care was provided. It's important to be as accurate as possible in this section.
5. Describe the nature of the incident or situation that required prehospital care. Provide a brief summary of what happened and why the care was necessary.
6. Explain the actions taken by the prehospital care providers. Include details about any treatments administered, medical procedures performed, or medications given.
7. If possible, provide contact information for any witnesses or individuals who can verify the details of the incident. This may include names, phone numbers, or any other relevant information.
8. Sign and date the form to acknowledge that the information provided is accurate and true to the best of your knowledge.
9. Submit the completed form to the appropriate authority or organization as instructed.

Who needs prehospital save nomination form:

1. Emergency medical service (EMS) personnel: This form is typically filled out by EMS personnel who were involved in providing prehospital care to a patient. They are responsible for documenting the details of the incident and the care provided.
2. Healthcare providers: In some cases, healthcare providers who were not directly involved in the prehospital care but have access to relevant information may also need to fill out the prehospital save nomination form. This can include physicians, nurses, or other healthcare professionals.
3. Patients or their representatives: Patients who have received prehospital care may be required to provide their consent or authorization for the nomination form to be filled out. In certain situations, their representatives (such as family members or legal guardians) may complete the form on their behalf.

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