TEMS Drug/IV Box Incdent On-line Form

Hampton Roads MMRS | Tidewater Center for Life Support | Eastern Shore | VA-1 DMAT

Wednesday, 19 June 2013

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If you are not able to submit your data by using this online form,
please print your information, make a note at the top of the problem you are having and fax your submission to the office at 757-963-2325.
Thanks.

TEMS Pre-Hospital IV and Drug Box Incident Report

Name / Title of Person Reporting:

Agency / Hospital of Reporting Person:

Phone Number:

E-Mail:

Date of Incident: example 01/01/03

IV (Orange) Box Number(s):

Drug (Red) Box Number(s):

If this incident involves Narcotics, the person reporting this incident will need to fill out and submit
The State Drug Diversion Form (Click here) to the Tidewater EMS Council by email or fax 757-963-2325.

EMS Agency Exchanging::

EMS Unit Exchanging:

Exchanging Pharmacy:

Last Restocking Pharmacy:

Description of incident/exchange including Names and Incident Numbers on the PPCRs: