Does the patient have an obvious injury or illness that requires further evaluation by a physician?

Yes____(obtain written refusal) No____(written refusal not required)

Does the patient complain of any symptoms that require further evaluation by a physician?

Yes____(obtain written refusal) No____(written refusal not required)

Is the patient "at risk" based upon history or mechanism of accident?

Yes____(obtain written refusal) No____(written refusal not required)

If the patient is a minor, is he/she 14 years of age or older?

Yes____(can refuse medical care - No____(can NOT refuse medical care - consider contacting parent/guardian) must contact parent/guardian)

Is the patient mentally impaired by alcohol, drugs, injury, physical or mental illness?

Yes____(patient can NOT refuse medical care - No____(can refuse medical care) contact Medical Control and law-enforcement)

Does the patient have an injury or illness that requires immediate medical attention?

Yes____(contact Medical Control) No____(consider Medical Control)

____ History of events

____ Patient's level of consciousness and competence

____ Physical assessment (including full set of vital signs)

____ The patient was informed, and understood, the need for further evaluation at an appropriate medical facility.

____ The patient was informed, and understood, the potential medical complications resulting from refusal of care.

____ The patient was informed, and understood, refusal in no way negates them from calling for or seeking medical assistance later.

____ The patient was offered a return to provide care at any time if needed.

____ At least (2) witnesses were present during the exchange between EMS personnel and the patient.

____ Witnesses have signed the PPCR. Signatures should be accompanied by printed name and address or ID number (badge #, Social Security #, etc.)