Policy Details

5141.12 FORM AED Event Summary

5141.12

FORM - Appendix II

STUDENTS

AED EVENT SUMMARY

This summary should be completed with input from all rescuers whenever possible.

Date of Event: ___________________________ Time of Event: _____________________

Location of Event: _____________________________________________________________________________________

Time arrived at patient's side with AED: ___________________________________

Patient's Name: ______________________________________________________________________________________

Sex: M / F Age: ____________

Name of AED Rescuer: ________________________________________________________________________________

911 Caller: ___________________________________________________________________________________________

CPR Rescuer: _______________________________________________________________________________________

Bystanders: _________________________________________________________________________________________

Transporting Ambulance Service: ________________________________________________________________________

Patient's condition at time of transport by AMR: _____________________________________________________________

____________________________________________________________________________________________________

____________________________________________________________________________________________________

Time patient transported: _____________________________________ Number of shocks

delivered: ____________________________

Signed by: __________________________________________________ Date: ________________________________

Summary rec: ­___/___/_____ Complete Y / N AED Restocked: ________

PC Card Reviewed by Program Physician: ___/___/_____ Reviewed with Rescuers: ___/__/___

Attach problems identified or comments.

Signature of Program Physician: ______________________________________________ Date: ­­­___/___/_____


Litchfield Board of Education
Form Adopted: February 15, 2006

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