Dispatch Diversion Log
Today's Date:
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Year
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Month
Day
Date
Current Time:
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:
Hour
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30
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50
Minutes
AM
PM
AM/PM Option
Ambulance Unit #:
Crew Member 1:
First Name
Last Name
Crew Member 2:
First Name
Last Name
Crew Member 3:
First Name
Last Name
Crew's Expected Deactivation Time
Ambulance Run#:
Pick Up Facility:
Requested Hospital:
Hospital Diverted To:
Sources of Diversion
Loyola University Medical Center
Northwest Community Hospital
St. Francis Evanston
St. Joe's Elgin
St. Mary's Kankakee
Vista East Medical Center
Crew Diversion
Patient Decision
Family Decision
Receiving Hospital Diversion
Reason For Diversion:
Person Notified At Sending Facility:
Submitted by
First Name
Last Name
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