Policy Text
KERN COUNTY SHERIFF'S OFFICE
AED DEFIBRILLATION REPORT
Case Number:
Assignment:
Date of Occurrence:
Time:
Patient Name:
Patient Age:
Witnesses to collapse/ cardiac arrest: Yes No
# of shocks:
Signature:
Date:
Name and Phone Number of Person Completing Report:
Additional Comments/Information:
AED Service Provider:
Time LE Notified:
Time of 1st shock (if given):
Patient regained pulse at scene: Yes No
Responder Name:
Responder Name:
Responder Name:
Responder Name:
Address where AED deployment occurred (include Zip Code):
Patient Gender: Male Female Other
Victim had pulse: Yes No
Victim was breathing: Yes No
Approx. time down prior to AED use:
CPR used prior to deployment: Yes No
SIGN
CLEAR FORM