AED Reporting Form

Use this form to report an AED deployment in your area.  (AED deployment is defined as meaning any time the device responds to an emergency medical incident but electrodes are NOT attached to the patient.)

As a reminder, if the AED is used (i.e. electrodes applied), you must fill out the MIEMSS Maryland Facility AED Report Form for Cardiac Arrests and send it to EHS within 24 hours of the incident.

*Denotes required fields.

Please provide the 
following contact 
information:

 *Name
Title
*Department
*Work Phone
FAX
*E-mail

*Responding Person:

*Building Where 
Incident Occurred:

*Room # or 
Location of Incident:

*Incident Date:

*Incident Time:

 AM  PM

Incident #: (If TUPD responded, what was the incident #?)

Comments:

 

                                                    

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