CIPS Team Member Reporting

CIPS Team Member Report

Important Notice about HIPPA and PHI

This form is for use by CSEMS Critical Incident Provider Support Team members only. Please complete one form for each intervention made.

This website is not compliant with the Health Insurance Portability and Accountability Act (HIPAA). Therefore, please do not submit Protected health information (PHI) in this form. PHI under US law is any information about health status, provision of health care, or payment for health care that is created or collected by a "Covered Entity" (or a Business Associate of a Covered Entity), and can be linked to a specific individual. This is interpreted rather broadly and includes any part of a patient's medical record or payment history.

Type of Intervention * Type of Intervention

Date of Intervention *

Reason for Request * Reason for Request

Time of Intervention *

Name of Team Members Present *

Location of Intervention

City

State/Province

Zip/Postal

How were you notified? * How were you notified?

Comments: *

Number of Responders Present

EMS Providers *

Fire *

Communications Staff *

Law Enforcement *

Hospital Staff *

Other *

Submitted By

First Name *

Last Name *

E-mail Address *

Phone Number *

Agency Follow-up Needed

Follow-up Contact Name

Phone

Certification Statement

I certify that the information submitted on this form is true and correct to the best of my knowledge. I understand have have reminded the team that any information discussed in this intervention is confidential. *

Agree

Disagree

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