AED - Incident Report

AED Incident Report

Please begin by typing in the ZIP code of the location where the AED is located. When a match is found then choose the facility from the dropdown. After you have chosen the facility you will be able to choose the particular AED used from the AED dropdown. If an AED is not registered in the ZIP code you are trying to use you will not be able to submit a report. Required fields are indicated with the red asterix (*).

Zip Code*

Facility*

AED*

Date and Time of Incident* (MM/DD/YYYY 23:00) :

First Responder*

First Name

Last Name

Second Responder

First Name

Last Name

Location

Age of Patient*

Gender of Patient

Cause of Incident

Estimated time that bystander performed CPR prior to arrival of AED

Estimated time of arrival of AED to initial shock delivered

Estimated Time of Arrival of Medical Responders after YOUR arrival

Total number of shocks administered

Incident Witnessed

Patient regained a pulse at the scene or during transport

Patient regained spontaneous respiration at the scene or during transport

Patient Transported

Comments