AED Usage Form | Tower Health

Completing the AED Usage Form is an essential part of tracking AED use in Berks County.

Required fields are marked with *

First Name

Last Name

Phone

Date of Use (if known)

AED Usage Information

Did YOU apply and use the AED?

Yes

If No, name of person who used AED

Location (municipality or description) where AED was used

Victim Information

Approximate age of victim

How was victim found?

Witnessed cardiac arrest, 9-1-1 called

Victim found unresponsive, (arrest not witnessed), 9-1-1 called

CPR initiated?

Yes

Number of shocks delivered by AED (if known)

Was the victim responsive following defibrillation with AED?

Yes

EMS and Hospital

Name of EMS service responding

Hospital receiving patient (if known)

Comments

Additional comments

The AED stores valuable data about the patient’s heart rhythm. It is important that this information becomes part of the patient’s medical record.

Following your submission, you may pick up a FREE QUIK-PAK (includes replacement electrodes and battery) in the Reading Hospital’s Emergency Department (ED) HIM group. To guarantee timely replacement, please complete the AED Usage Form within 48 hours of AED use and check in with the ED to download your AED and pick up your QUIK-PAK.