NOTE:

For official copies of board policies and procedures please contact the superintendent's office at (253) 583-5190 or email supt@cloverpark.k2.wa.us

Form 3412-F2

CLOVER PARK SCHOOL DISTRICT
AED INCIDENT FORM

Complete this form with every incident necessitating AED use, submitting within 24 hours of use.

DATE AND TIME OF AED USE:

AED SERIAL NUMBER:

STUDENT’S ID NUMBER (If applicable):

DOB: AGE: SEX: F or M PHONE:

ALLERGIES:

CURRENT MEDICATIONS:

PERTINENT MEDICAL HISTORY:

EXACT LOCATION OF INCIDENT:

DESCRIPTION OF INCIDENT:


 

WITNESSES: PHONE NUMBER:

NAME OF AED OPERATOR:

OTHER ASSISTING RESPONDERS:

EMS UNIT RECEIVING PERSON:

TIME AND LOCATION OF TRANSPORT:

REPORTED BY: DATE:

PHONE NUMBER:

MEDICAL DIRECTOR’S COMMENTS:

Copy Distribution: Risk Management, Facility Coordinator