LSA Demographics

Name of Life Support Agency (LSA):*

LSA Type:*

LSA License Level:*

LSA Transport Status:*

Cardiac Arrest Data

Each OCMCA LSA is required to assure that specific data is submitted to the Cardiac Arrest Registry to Enhance Survival (CARES). Contact the OCMCA with any questions with complying with this requirement at QI@OCMCA.org.

Select an option from the dropdown menu that best describes your LSA:*

What is the total number of cardiac arrests that your LSA responded to during this reporting period?*

Has your LSA entered the necessary information into CARES for all applicable cardiac arrest runs that your LSA responded to during this reporting period?*

Yes
No

Please explain why your LSA was unable to meet the CARES reporting requirements:*

Has your LSA supplied all of the necessary CARES reporting data to the LSA that provides EMS transport in your LSA’s geographic service area?*

Yes
No

Please explain why your LSA was unable to meet the CARES reporting requirements:*

Has your LSA, entered all necessary information into CARES for all applicable cardiac arrest runs that your LSA is responsible for during this reporting period?*

Yes
No
Another LSA is responsible to complete CARES reports for all of our cardiac arrest patients.

Please explain why your LSA was unable to meet the CARES reporting requirements:*

Has your LSA supplied all of the necessary CARES reporting data to the LSA that provides EMS transport in your LSA’s geographic service area?*

Yes
No

Please explain why your LSA was unable to meet the CARES reporting requirements:*

Please complete the following questions

Has your LSA ensured that all ePCRs have been uploaded to MIEMSIS?*

Yes
No

Have you submitted to the OCMCA, a personnel list for this reporting period? If no, submit a current list to Amy at ems@ocmca.org, using the EQIP required instructions/format. Contact Amy at ems@ocmca.org for complete instructions.*

Yes
No

Has your LSA responded to any Mass Casualty Incidents during this reporting period? If yes, please notify qi@ocmca.org and submit a copy of all ePCRs, if you have not already.*

Yes
No

Has your LSA activated a helicopter for an emergent scene transport? If yes, please notify qi@ocmca.org and submit a copy of all ePCRs, if you have not already.*

Yes
No

Has any of the information on your LSAs Letter of Compliance changed since it was submitted? If yes, submit all changes through the digital LSA Letter of Compliance process. This includes updates to the LSA primary contact information.*

Yes
No

Does your LSA carry supplies/equipment that is not listed on the State of Michigan approved equipment list, and has not been approved by the OCMCA PSRO Committee? If yes, please notify qi@ocmca.org.*

Yes
No

Have you notified your EMS Providers of all new or updated Protocols, in this reporting period?*

Yes
No

EQIP Reporting Compliance

Name of LSA Representative submitting this form:*

Email:*

Phone:*

Digital Signature:*

By digitally typing your signature, you affirm that you are an approved representative of your LSA, and the information contained within this report is accurate.