Common use of Reporting Templates Clause in Contracts

Reporting Templates. Response Time Performance Provider Period Date Urban Rural Remote Immediately Life threatening emergency incidents Potentially life threatening emergency incidents Immediately Life threatening emergency incidents Potentially life threatening emergency incidents Immediately Life threatening emergency incidents Potentially life threatening emergency incidents 50% 95% 80% 50% 95% 80% 50% 95% 80% 8 minutes 20 minutes 20 mintues 12 minutes 30 minutes 30 minutes 25 minutes 60 minutes 60 minutes Jul-09 Sep-09 Oct-09 Nov-09 Dec-09 Mar-10 Apr-10 May-10 Jul-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11 Apr-11 May-11 Jun-11 Jul-11 Volume Reporting Provider Period Date Volume of incidents attended where there was no patient transported Volume of incidents attended where there was at least one patient transported Immediately life threatening Potentially life threatening Non-emergency Sep-09 Oct-09 Nov-09 Dec-09 Mar-10 Apr-10 May-10 Jul-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11 Apr-11 May-11 Jun-11 Jul-11 Front Line Staffing Provider Period Date ALS ILS BLS Total Full Time Equivalent Paid Establishment Full time Equivalent vacancies for paid positions Headcount of volunteers Appendix 4: Allocating the Severity Assessment Code (SAC Score) Source: xxxx://xxx.xxx.xxxx.xx/moh.nsf/indexmh/improvingquality-reportableevents-resources Appendix 5: Serious and Sentinel Events Quarterly Reporting Template Incidents - Quarterly Report Reported by: (name) Operator: (select) Date Reported: (date) Year: 2010/11 Quarter: (select) Required fields Required for SAC1 and SAC2 events (not required for SAC3 & SAC4) If known: Organisation Event Ref Date Reported to NASO Type of Incident Date of incident Region Serious, Sentinel or Adverse Actual / Potential (Near Miss) Actual Severity Assessment Code (SAC) Score Incident Category Description of what happened and immediate actions taken Final SAC Score (following investigation / mitigation) Findings/Outcome of Investigation Recommendations Mitigation (Investigation / Response / Actions) Media coverage (if any) Media Story (if any) Complaint? Incident Number (select) (select) (select) (select) (select) (select) (select)

Reporting Templates. Response Time Performance Provider Period Date Urban Rural Remote Immediately Life threatening emergency incidents Potentially life threatening emergency incidents Immediately Life threatening emergency incidents Potentially life threatening emergency incidents Immediately Life threatening emergency incidents Potentially life threatening emergency incidents 50% 95% 80% 50% 95% 80% 50% 95% 80% 8 minutes 20 minutes 20 mintues 12 minutes 30 minutes 30 minutes 25 minutes 60 minutes 60 minutes Jul-09 Sep-09 Oct-09 Nov-09 Dec-09 Mar-10 Apr-10 May-10 Jul-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11 Apr-11 May-11 Jun-11 Jul-11 Volume Reporting Provider Period Date Volume of incidents attended where there was no patient transported Volume of incidents attended where there was at least one patient transported Immediately life threatening Potentially life threatening Non-emergency Sep-09 Oct-09 Nov-09 Dec-09 Mar-10 Apr-10 May-10 Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11 Apr-11 May-11 Jun-11 Jul-11 Front Line Staffing Provider Period Date ALS ILS BLS Total Full Time Equivalent Paid Establishment Full time Equivalent vacancies for paid positions Headcount of volunteers Appendix 4: Allocating the Severity Assessment Code (SAC Score) Source: xxxx://xxx.xxx.xxxx.xx/moh.nsf/indexmh/improvingquality-reportableevents-resources Appendix 5: Serious and Sentinel Events Quarterly Reporting Template Incidents - Quarterly Report Reported by: (name) Operator: (select) Date Reported: (date) Year: 2010/11 Quarter: (select) Required fields Required for SAC1 and SAC2 events (not required for SAC3 & SAC4) If known: Organisation Event Ref Date Reported to NASO Type of Incident Date of incident Region Serious, Sentinel or Adverse Actual / Potential (Near Miss) Actual Severity Assessment Code (SAC) Score Incident Category Description of what happened and immediate actions taken Final SAC Score (following investigation / mitigation) Findings/Outcome of Investigation Recommendations Mitigation (Investigation / Response / Actions) Media coverage (if any) Media Story (if any) Complaint? Incident Number (select) (select) (select) (select) (select) (select) (select)

Reporting Templates. Response Time Performance Provider Period Date Urban Rural Remote Immediately Life threatening emergency incidents Potentially life threatening emergency incidents Immediately Life threatening emergency incidents Potentially life threatening emergency incidents Immediately Life threatening emergency incidents Potentially life threatening emergency incidents 50% 95% 80% 50% 95% 80% 50% 95% 80% 8 minutes 20 minutes 20 mintues 12 minutes 30 minutes 30 minutes 25 minutes 60 minutes 60 minutes Jul-09 Sep-09 Oct-09 Nov-09 Dec-09 Mar-10 Apr-10 May-10 Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11 Apr-11 May-11 Jun-11 Jul-11 Volume Reporting Provider Period Date Volume of incidents attended where there was no patient transported Volume of incidents attended where there was at least one patient transported Immediately life threatening Potentially life threatening Non-emergency Sep-09 Oct-09 Nov-09 Dec-09 Mar-10 Apr-10 May-10 Jul-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11 Apr-11 May-11 Jun-11 Jul-11 Front Line Staffing Provider Period Date ALS ILS BLS Total Full Time Equivalent Paid Establishment Full time Equivalent vacancies for paid positions Headcount of volunteers Appendix 4: Allocating the Severity Assessment Code (SAC Score) Source: xxxx://xxx.xxx.xxxx.xx/moh.nsf/indexmh/improvingquality-reportableevents-resources xxxx://xxx.xxx.xxxx.xx/xxx.xxx/indexmh/improvingquality-reportableevents-resources Appendix 5: Serious and Sentinel Events Quarterly Reporting Template Incidents - Quarterly Report Reported by: (name) Operator: (select) Date Reported: (date) Year: 2010/11 Quarter: (select) Required fields Required for SAC1 and SAC2 events (not required for SAC3 & SAC4) If known: Organisation Event Ref Date Reported to NASO Type of Incident Date of incident Region Serious, Sentinel or Adverse Actual / Potential (Near Miss) Actual Severity Assessment Code (SAC) Score Incident Category Description of what happened and immediate actions taken Final SAC Score (following investigation / mitigation) Findings/Outcome of Investigation Recommendations Mitigation (Investigation / Response / Actions) Media coverage (if any) Media Story (if any) Complaint? Incident Number (select) (select) (select) (select) (select) (select) (select)