SWORBHP Prehospital Save Award

If you have done a call that you feel meets or potentially meets the criteria to be considered for a
Prehospital Save Award, please complete the following form and submit to the Base Hospital for
follow-up and verification. Please do not include any personal patient information on this form.

Prehospital Save Criteria:

Paramedic crew present a patient to the ED with a prehospital ROSC and patient is discharged
from hospital. Paramedic crew present a viable patient to the ED, patient is resuscitated in the ED and patient
is discharged from hospital. If you are unsure if the patient was resuscitated in the ED, please
complete this form and we will attempt to verify patient outcome.

Call Date:

Service:

Run #:

Email address of person completing this form:

Paramedic Information:

First Name:

Last Name:

OASIS #:

Add another Paramedic?

First Name:

Last Name:

OASIS #:

Add another Paramedic?

First Name:

Last Name:

OASIS #:

Add another Paramedic?

First Name:

Last Name:

OASIS #:

Add another Paramedic?

First Name:

Last Name:

OASIS #:

Add another Paramedic?

First Name:

Last Name:

OASIS #:

Add another Paramedic?

First Name:

Last Name:

OASIS #:

Add another Paramedic?

First Name:

Last Name:

OASIS #:

Add another Paramedic?

First Name:

Last Name:

OASIS #:

Add another Paramedic?

First Name:

Last Name:

OASIS #: