EZ-IO Regional Administration Program

This Form is intended to assisit NTRAC and the NORTEX EMS Provider's Association in surveillance of our EZ-IO program. Please fill out this formcompletely after each insertion of a needle using this device. Please do not place any Protected Health Information (PHI) on this form. This information will be kept secure and used in an effort of process improvement and data collection. A completed form will be necessary to obtain a replacement needle from the NTRAC/NREMSPA program.

Q1	Agency

Q2	Date of Incident

Patient Classification

Medical

Trauma

Other

	If other, please specify

	If other, please specify

Device Indicators

Patient Demographic

Class

Infant

Pedi

Adult

Geriatric

Body Type

Thin

Average

Obese

Site Selection check all that apply

Tibia

Humerous

Sternum

	If humerus not used, please specify.

Securement Method

Stabilizer

None

Other

	If other, please specify.

Q9	Insertions
Q9		1	2	3+
	Attempted Insertions	Attempted Insertions 1	Attempted Insertions 2	Attempted Insertions 3+

	Successful Insertions	Successful Insertions 1	Successful Insertions 2	Successful Insertions 3+

	If more than one attempt, please specify issue with insertion.

Q10

Insertion Device

Driver

Manual

Q11

Analgesic

Lidocaine

None

Q12

Placement Verification

Aspiration

Flow

Determining Factor(s)

	If other, please specify:

Administration

Q14

Primary Use

Volume

Med Admin

Results

Q15

Device Performed as Expected

Yes

	If no, why?

Q16

Training for Task

Good

Adequate

Need Additional Training

Q17	Comments: