HomeMy WebLinkAboutaed-use-form
Revised January 2013
ALAMEDA COUNTY HEALTH CARE SERVICES AGENCY
EMERGENCY MEDICAL SERVICES AGENCY
1000 San Leandro Blvd. Suite 200 San Leandro, CA 94577
(510) 618-2050 Fax: (510) 618-2099
Public Access Defibrillation
AED Use Notification
Incident Information Insert Information Here
Business Name of AED Program
Address of Incident
Contact Name
Contact Number
Name of Person Who Used the AED
Date of Incident
Time of Incident
Patient’s Name (if known)
Patient’s Age (estimate if unable to confirm)
Patient’s Sex
Time CPR Was Started
Name of Person(s) Who Did CPR
Total Number of Defibrillations Delivered
Date and Time Your Medical Director
Was Notified
Medical Director’s Name
Medical Director’s Number
Please attach any additional information that you think might be helpful.
Please fax or mail a copy of this form to the EMS office within 24 hours of the incident.
Fax Number: 510-618-2099
Attn: AED/PAD Program Coordinator
Alameda County EMS, 1000 San Leandro Blvd. 2nd floor, San Leandro, CA 94577