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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 * (MM/DD/YYYY 23:00)
  • / / :
  • First Responder First Name*
    First Responder Last Name*
  • Second Responder First Name
    Second Responder Last Name
  • Location
  • Age of Patient *
  • Gender of Patient
  • Male Female
  • Cause of Incident
  • Medical Trauma
  • Estimated time that bystander performed CPR prior to arrival of AED
  • None Unknown < 4 Minutes 4-8 Minutes 8-12 Minutes > 12 Minutes
  • Estimated time of arrival of AED to initial shock delivered
  • Unknown < 4 Minutes 4-8 Minutes 8-12 Minutes > 12 Minutes
  • Estimated Time of Arrival of Medical Responders after YOUR arrival
  • Unknown < 4 Minutes 4-8 Minutes 8-12 Minutes > 12 Minutes
  • Total number of shocks administered
  • Incident Witnessed
  • Yes No Unknown
  • Patient regained a pulse at the scene or during transport
  • Yes No Unknown
  • Patient regained spontaneous respiration at the scene or during transport
  • Yes No Unknown
  • Patient Transported
  • Yes No
  • Comments
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