, resuscitation council (uk) this form should be · 2013-03-26 · when aed / defibrillator was...
TRANSCRIPT
Unknown D
This form should becompleted in all caseswhen AED / defibrillatorwas used, regardless ofwhether shocks weregiven or not
Estimated D
Date of incident(dd/mmNyyy)
Organisation responsible for the defibrillator I(e.g. Name of First Responder group, GP, Police Force etc.) _
Sex (v) Male D Female D Unknown D Age 1 Y_ea_rs_1Known D
., Resuscitation Council (UK) EVENT REPORT FORM
Home DLeisure centre/Gym D
Other location DRailway station D
Place of collapse Tick (v) one box only:
Airport DBus station D
Doctor's surgery DExhibition/Conference DSpecific place or address of collapse(e.g. Luton Airport, Sports Centre Penarth Road Cardiff, etc.)
Remote location DRoad Traffic Accident D
Shopping centre DSporting event D
Street DUnknown D
Underground railway DWorkplace D
No D Unknown D
Rescuer with defibrillator D
Time the event was notified to central ambulance control (where applicable)
Time delay between collapse and placingMinutes Ithe electrodes on the victim's chest
Was a shock given? (v) Yes D NoD
If YES, what was the total number of shocksShocks Igiven before the ambulance arrived?
Did the victim have signs of circulationYes D No DAFTERany shock was administered? (••••.)
Did the victim start breathing or recoverYes D No Dconsciousness before the ambulance arrived? (v)
Measured D Estimated D Unknown D
Minutes IUnknown D
Other person D
Hours I I
Unknown D
Unknown D
Unknown D
Measured D Estimated D
Unknown D
NoD
Minutes I
Yes D
Yes D
Was the collapse witnessed? (v)
If YES, please indicate by whom (v)
Was CPR started beforethe defibrillator arrived? (v)
What was the delay between the victimcollapsing and the start of CPR?
Unknown D
I
Other DUnknown D
C.DATA? (v)
Yes DNo D
Unknown D
Discharged alive D
'REGION (••••.)
England DNorthern Ireland D
Other DScotland D
Unknown D I EventreI:Wales D _
Was the victim: Tick (••••.) one box onlyAlive not transferred to hospital D Transferred to hospital* - no circulation D *Hospital name:
Recognised dead at the scene D Transferred to hospital* - with circulation DTransferred to hospital* - CPR in progress D L-- --'
Victim's status after transfer to hospital: Tick (v) one box only
Dead on arrival D Admitted, but did not survive to discharge DI Additional informallon
FOR OFFICE USE ONLY. PLEASE DO NOT COMPLETE THIS SECTIONSUPPLIER (••••.) OUTCOME (v)
BHF D Dead on arrival at hospital DDOH D Died in hospital D
Other D Recognised dead at scene DSurvived to discharge D
I-o-rga-n-is-all-.on-:-------I Unknown D
PLEASE SEND THE WHITE COPYAS SOON AS POSSIBLE TO:The Resuscitation Council (UK), 5th Floor, Tavistock House North, Tavistock Square, London WC1H 9HR
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