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

Title/Position

First Name

Last Name

Date and Time of Incident

Event Number

Agency Affiliation

Your Email Address

A copy of the SVR will be sent to the email entered.

Email Additional Recipients

If you would like to send a copy of this SVR to your EMS Program Manager you may insert their email address here. Multiple email addresses may be seperated by a comma.

Phone

Incident Reported To

Level A Variance

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

Level B Variance

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

Level C Variance

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

Narrative

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