Automated External Defibrillators
RISE Charter School
AUTOMATED EXTERNAL DEFIBRILLATOR (AED)
INCIDENT REPORT
Date of Incident: Time of Incident:
Location of Incident (which building, where in building, etc.):
Patient’s Age: Patient’s Gender: Male Female
CPR prior to defibrillation: Attempted Not Attempted
Cardiac Arrest: Not Witnessed Witnessed by Bystander
Witnessed by AED team member
Estimated time (in minutes) from arrest to CPR:
Shock: Indicated Not Indicated
Estimated time (in minutes) from arrest to 1st AED shock:
Number of shocks:
Additional Comments:
Patient Outcome at Incident Site:
_____ Return of pulse and breathing _____ No return of pulse or breathing
_____ Return of pulse with no breathing _____ Became responsive
_____ Return of pulse, then loss of pulse _____ Remained unresponsive
Name of AED Operator:
Transporting Ambulance:
Name of Facility Patient was Transported to:
Name of Emergency Health Care Provider:
Signature of Health Care Provider Date of Report
This report is to be completed by the Emergency Health Care Provider or AED User within 5 business days of use of an AED.
The completed report must be mailed/ret