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Performance Improvement Committee System Referral
Department*:
please select
Agency
Hospital
Speciality Care Transports
Date of Referral*:
Referred By*:
Email Address*:
Phone Number*:
Patient Age:
Patient Gender:
please select
Male
Female
MOI (Mechanism of Injury)
Check all that appy
:
ATV
Aircraft
Animal
Assault
Bicycle
Burn
Dirt Bike
Electrical
Fall
GSW
MVC
Machinery
Pedestrian
Sports
Stab
Struck by object
Other
Date of Service*:
Reason for Referral:
please select
Death within 48 hours after arrival at definitive care
Transfers greater than 6 hours
Scene times greater than 20 minutes
Inability to secure an airway
Surgical airway
Inadvertent loss of airway
Other
If Other, please explain:
Number Verify*:
91313
*required fields