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Security Services
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
AM
PM
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
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
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
AM
PM
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
AM
PM
Did the victim begin breathing again?
*
Yes
No
Unknown
If began again, time the victim began breathing again
*
:
Hours
Minutes
AM
PM
Did the victim ever regain consciousness?
*
Yes
No
Unknown
If regained, time the victim regained consciousness
*
:
Hours
Minutes
AM
PM
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
AM
PM
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.