Policy Details

5141.12 FORM AED Event Summary

5141.12

FORM - Appendix II

STUDENTS

AUTOMATED EXTERNAL DEFIBRILLATOR (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: 2/15/2006
Form Revised: 7/30/2020

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