ODEMSA Drug Box Discrepancy Report
Please complete the following information
Name of person reporting discrepancy:
*
Mr/Ms/Mrs
FIRST NAME
LAST NAME
TITLE-ie pharmacist, paramedic, etc
What Pharmacy or EMS Agency agency are you with?
*
Email - Point of Contact
*
example@example.com
Phone - Point of Contact
*
-
Area Code
Phone Number
Date and time discrepancy occurred?
*
-
Month
-
Day
Year
Date
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Date and time when discrepancy recognized?
*
-
Month
-
Day
Year
Date Picker Icon
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
EMS Incident Number
*
Drug Box Number
*
What is the discrepancy?
*
Any Further Comments
Optional Image Upload
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