ODEMSA Discrepancy Report Form

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