EMS Medical Forms

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AED Notification of Placement Form NOTIFICATION OF AED PLACEMENT - Orange County Health Care Agency, Emergency Medical Services Notification of a new or update to an existing AED provider (Also known as Public Access)

Form - ALS Services Provided Without Base Hospital Contact -pdf file

AED USE EVENT SUMMARY FORM To be completed on attempted or actual use of AED.

Form - ALS Services Provided Without Base Hospital Contact -pdf file

ALS Services Provided Without Base Hospital Contact - Form Accompanying form for P&P 330.15 This policy defines the steps to be followed in the event that a patient requires advanced life support interventions for which on-line medical control is required and the EMT-P is unable to establish or maintain communications with the assigned base hospital.

Form - ALS Services Provided Without Base Hospital Contact -pdf file

FAQ: Do Not Resuscitate (DNR) Form

download Instructions: Do Not Resuscitate (DNR) Form -pdf file

Do Not Resuscitate (DNR) Form This pre-hospital form has been developed by the California Emergency Medical Services Authority, in concert with the California Medical Association and emergency medical services (EMS) providers, for the purpose of instructing EMS personnel to forgo resuscitation attempts in the event of a patient’s cardiopulmonary arrest. Click here for more information

download Do Not Resuscitate (DNR) Form-pdf version

Emergency Information Form for Children with Special needs This information form should be filled out by the child’s attending pediatrician, or in some cases, by another physician responsible for the child’s on-going care. The information form is aimed at children who have chronic illnesses and are likely to require treatment by paramedics and/or in an emergency department. The information form is designed to make important medical information rapidly available to paramedics and emergency department physicians.

Once the information form is filled out, it should be kept in the child’s home where it will be readily accessible to rescuers (perhaps on the refrigerator). Families should be encouraged to carry a second copy with them, and have one with the child if away from the parents. It is the family’s responsibility to keep the form up-to-date, or to have the child’s physician update the form.

Please copy or download the information form on pink paper for distribution. Paramedics are being taught to look for a pink form in the home. Pink is for pediatrics (children).

download Emergency Information Form - pdf version

Sample: Emergency Information Form for Children with Special needs Sample of the form filled out.

Sample: download Emergency Information Form for Children with Special needs - pdf version

Emergency Information Form for Adults This information form should be filled out by your attending physician, or in some cases, by another physician responsible for your on-going care. The information form is aimed at adults who have chronic illnesses and are likely to require treatment by paramedics and/or in an emergency department. The information form is designed to make important medical information rapidly available to paramedics and emergency department physicians.

Once the information form is filled out, it should be kept in your home where it will be readily accessible to rescuers (perhaps on the refrigerator). Families should be encouraged to carry a second copy with them, and you should have one at all times. It is your responsibility to keep the form up to date, or to have your physician update the form.

download Emergency Information Form for Adults-pdf version

Sample: Emergency Information Form for Adults

Sample of the form filled out.

download Sample: Emergency Information Form for Adults - pdf version

Suspected Elder Abuse Report Form Additional reporting information is available at the Orange County Social Services Web site.

download Suspected Elder Abuse Report - pdf version

Suspected Child Abuse Report Form The form and additional reporting information is available at the Orange County Social Services Web site.

download Suspected Elder Abuse Report - pdf version