System Variance Reporting

The following form may be used to submit a System Variance Report to the EMS Agency. Please do not include personal health information in the report. If you have attachments that need to be included with the report please email them directly to [email protected] and include the event # associated with the incident in the body of the email. If this information is unknown please include the date and time of the incident.

For questions about system variances please reference EMS Policy 108

Report a System Variance


Threat to Public Safety
Negative Patient Outcome due to Medication Error or Policy Violation
Public Concern

Potential Clinical Care Variance
Potential Policy Variance
Interagency Coordination
General Complaint
Communications System Variance
Other: Please describe in Narrative

Good Patient Outcome
Outstanding Service
Excellence in the Line of Duty
Other: please describe in narrative

Include specific and detailed information about the incident, location, times, persons involved, witnesses, actions taken, notifications given, and anything else relevant. 

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