AED Incident Report

AED Incident Report - Online Version

Responder, use this form to report any event, incident, or situation that resulted in the use or attempted use of an AED.

Incident Information
Incident Date
MM slash DD slash YYYY
Incident Time*

: HH

MM
Incident Location*
Victim Information
Victim's Name*
First Last
Victim's Gender*
- Female
- Male
- Other
Victim's Approximate Age*
Do you know the victim's home address?
- Yes
- No
If yes, provide the victim's address
Street Address Address Line 2 City State ZIP Code
Operator(s) Information
AED Operator's Name*
First Last
Other Person Involved name (if applicable)
First Last
Other Person Involved name (if applicable)
First Last
Incident Data
Was cardiac arrest witnessed?*
- Yes
- No
- Unknown
If witnessed, name of witness*
First Last
Was CPR started?
- Yes
- No
If started, who started it?
First Last
If started, time CPR was started

: Hours

Minutes
Was an AED applied?*
- Yes
- No
If applied, how many shocks did the AED administer?
If applied, describe the actions the AED advised*
Did the victim regain a pulse?*
- Yes
- No
- Unknown
If regained, time pulse was regained*

: Hours

Minutes
Did the victim begin breathing again?*
- Yes
- No
- Unknown
If began again, time the victim began breathing again*

: Hours

Minutes
Did the victim ever regain consciousness?*
- Yes
- No
- Unknown
If regained, time the victim regained consciousness*

: Hours

Minutes
Emergency Responder Information
Were Carleton College Security Services notified?*
- Yes
- No
Did Carleton College Security Services respond to the scene?*
- Yes
- No
Was a verbal report provided to a Security Services officer?*
- Yes
- No
- Unknown
If provided, who provided the verbal report to a Security Services officer?*
First Last
Was the EMS system activated (911 call)?*
- Yes
- No
If activated, what time was the EMS system activated (911 called)?*

: Hours

Minutes
Did any EMS responders (police, fire, EMS) receive a verbal report?*
- Yes
- No
- Unkown
If provided, who provided the verbal report to the EMS responders?*
First Last
Did EMS responders request a data download from the AED unit?*
- Yes
- No
- Unknown
What is the police report number?
Post-Incident Action
Was the AED unit turned over to a Security Services officer for cleaning and re-stocking?*
- Yes
- No
- Unknown
- Not Applicable
Signature of the responder who completed this form*

Type your name into the field.
I acknowledge this form is filled out completely and accurately.*
Final instructions
Click on the "Submit" button to finalize and transmit the form to Security Services.
Phone
This field is for validation purposes and should be left unchanged.