Please complete this electronic form and submit it to the South Jordan City Fire Department within 24 hours of providing assistance to a Sudden Cardiac Arrest patient, regardless of whether or not an AED was available and/or used. The information contained herein will be used by our quality assurance team to assist with evaluating the effectiveness of the Heart Safe Program and making adjustments as appropriate. The information is critical to the success of this program.
Private information contained in this report will remain confidential to the full extent as allowed by the Utah Governmental Records Access Management Act.
Contact Information
*indicates a required
field
| Entity (if applicable) |
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| * Contact Name |
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| Address |
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| City, State, Zip |
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| * Contact Phone |
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| Email |
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Rescuer Information
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| Rescuer Name |
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| Address |
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| City, State, Zip |
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| Contact Phone |
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| Action by this rescuer |
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| Rescuer Name |
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| Address |
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| City, State, Zip |
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| Contact Phone |
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| Action by this rescuer |
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Incident Information
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| *Incident Address |
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| *Location Type |
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| *Incident Date |
Select Date |
| *Incident Time |
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| *Patient Gender |
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| Patient Age (if known) |
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| *Patient activity prior to event |
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| *Patient complaint prior to event |
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| * Was the event witnessed? |
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| * Bystander CPR Performed |
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| * Event to CPR Time (est.) |
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| * Initial AED Provided By |
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| * Event to Shock Time (est.) |
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* Number of shocks delivered
prior to arrival of EMS |
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| * Was respiration regained? |
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| * Was conciousness regained? |
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| * Patient Transported By |
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AED Information
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| * AED Make |
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| * Did the AED Work Properly? |
Yes No (if no, explain in comments section)
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Additional Information/Comments
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| * Form completed by |
Date: |
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