Contact Us | Hampton Roads MMRS | Eastern Virginia Healthcare Coalition | Tidewater Center for Life Support | Eastern Shore | VA-1 DMAT
Thursday, 18 December 2014

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If you are not able to submit your data by using this online form,
please print your information, make a note at the top of the problem you are having and fax your submission to the office at 757-963-2325.

Tidewater EMS Regional PI Form

The purpose of this referral is to improve the quality and efficiency of patient care in the Tidewater region. This form is intended for positive and negative comments regarding EMS incidents in the Tidewater region. Submission of this document initiates further review of the specific incident. The intent of this form is to identify "system" issues. All information obtained through this process will remain confidential. This information will be used by the EMS Agency and Operational Medical Director (OMD) for the purposes of Quality Improvement (QI) and Performance Improvement (PI) with the ultimate goal being improved patient care and offer solutions to improve the system as a whole.

This form may be submitted anonymously.

Please select the correct PI Form:   

Please select a reason for this referral:

Pursuant to sections ยง 8.01-581.16, 8.01-581.17, 32.1-116.2, of the Virginia Codes, data or information in the possession of or transmitted to the Commissioner, the Advisory Board, or any committee acting on behalf of the Advisory Board, any hospital or prehospital care provider, or any other person shall be privileged and shall not be disclosed or obtained by legal discovery proceedings, unless a circuit court, after a hearing and for good cause shown arising from extraordinary circumstances, orders disclosure of such data.