Cornell University AED Incident Report

Patient and Incident Information

Campus:            _________________________          Date of Incident:  ______________

Patient Name:   _________________________          Patient DOB:        ______________

Patient’s Address: _______________________          Patient Age:         ______________

City/State/Zip:     _______________________            Patient Sex:           M   /   F

EVENT HISTORY

 Patient Activity Prior to event:         _____________________________________________

Patient Complaints Prior to event:     _____________________________________________

           Event Witnessed:   Y  N       Time:  ______________           By:  ____________

                 CPR Initiated:   Y  N      Time:  ______________           By:  ____________

Assessment / Treatment

             ABCs Assessed:   Y  N      Time:   ______________          By:  ____________________

                CPR Initiated:   Y  N      Time:  _______________         By:  ____________________

      Shock # 1 Delivered:   Y  N     Time:  _______________         By:  ____________________

     Shock # 2 Delivered:   Y  N     Time:  _______________          By:  _____________________

     Shock # 3 Delivered:   Y  N     Time:  _______________         By:  _____________________

                          AED Effective:   Y  N     Time:  _______________

                Respiration Regained:   Y  N    Time:  _______________

                   Transferred to EMS:   Y  N    Time:  _______________

             Transported to Hospital:   Y  N    Time:  _______________

COMMENTS

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ADMINISTRATIVE

   Completed by:  _______________________________________  Date:  ________________

   Other Team Members Present:  _________________________________________________

       AED Coordinator Review:  ___________________________  Date:  _________________

               Forwarded to EHCP:  ___________________________  Date:  __________________

Upon Completion of Form:

1. Forward to EHCP
2. Maintain in secured fashion by Campus AED Coordinator
3. **If a SUNY Unit Fax to SUNY System Administration, AED Administrative, 518/443-5605