AED Reporting Form

If the AED is deployed on campus, meaning it responded to an emergency medical incident but the electrodes were NOT attached to the patient, please fill out the following form:

Please provide the following contact information:

Section

Name:

Title:

Department:

Work Phone:

Fax:

E-Mail Address:

Responding Person:

Building Where Incident Occurred:

Room # or Location of Incident:

Incident Date:

Incident Time:

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AMPM

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

Comments: