# # Ambulance Location Transport Annual EHR Proposed Provider (City) Emergency Vendor Name Responses Participant (Yes/No) 1 2 3 4 5 6 Summary % of Emergency Ambulance Providers Proposed to participate (Participants/ total ambulance providers) % of Emergency Responses (Volume of Participating Providers/Total Emergency Responses) CHART B SAMPLE EMS Receiving Hospitals (List all in LEMSA Area) # EMS Location Base Annual EHR Proposed Receiving (City) Hospital Ambulance Vendor Grant Hospital (Yes/No) Transports Participant Name Received (Yes/No) 1 2 3 4 5 6
Ambulance Provider Name Location (City) # Transport # Annual Emergency Responses EHR Vendor Proposed Participant (Yes/No) 1 2 3 4 5 6 Summary % of Emergency Ambulance Providers Proposed to participate (Participants/ total ambulance providers) % of Emergency Responses (Volume of Participating Providers/Total Emergency Responses) CHART B SAMPLE EMS Receiving Hospitals (List all in LEMSA Area) EMS Receiving Hospital Name Location (City) Base Hospital (Yes/No) # Annual Ambulance Transports Received EHR Vendor Proposed Grant Participant (Yes/No) 1 2 3 4 5 6
EMS-GFO-2018-Sept-v1-3.docx