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ODEMSA Discrepancy Report Form
1
Date and time discrepancy occurred?
*
This field is required.
Can be approximate
Date
Month
Day
Year
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Hour
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50
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40
50
Minutes
AM
PM
PM
AM
PM
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2
Date and time when discrepancy recognized?
*
This field is required.
Date
Month
Day
Year
1
2
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12
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12
Hour
00
10
20
30
40
50
00
10
20
30
40
50
Minutes
AM
PM
PM
AM
PM
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3
What facility or EMS agency are you?
*
This field is required.
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4
Name of person reporting discrepancy:
*
This field is required.
Mr/Ms/Mrs
FIRST NAME
LAST NAME
TITLE-ie pharmacist, paramedic, etc
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5
Email - Point of Contact
*
This field is required.
example@example.com
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6
Phone - Point of Contact
*
This field is required.
Area Code
Phone Number
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7
EMS Incident Number
*
This field is required.
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8
Drug Box Number
*
This field is required.
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9
What is the discrepancy?
*
This field is required.
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10
Any Further Comments
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11
Optional Image Upload
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: 10.6MB
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