Customer Event Form Reporter InformationEvent Reporter Name*TelephoneEmail* Distributor NameUser InformationCountry (if unknown, enter N/A)*Was user trained?YesNoTraining Provider (if known)Device InformationDevice TypeSAM 300SAM 300PSAM 350PSAM 360PSAM 450PSAM 500PPDU 400Device Serial NumberDevice Software VersionPad-Pak InformationPad-Pak TypePad-PakPediatric-PakPad-Pak Lot/Serial NumberPad-Pak Expiration DatePatient InformationGender*MaleFemaleNon-Binary/Third GenderAge in Years (if unknown, enter N/A)*Weight in Kgs (Estimation)Time of Use (Local)Date of Use Date Format: MM slash DD slash YYYY Pre-Existing Medical Conditions (if known)Please check all that apply. Diabetes Mellitus Hypertension Hyperlipidaemia Implanted Pacemaker Please list other known conditions.Event InformationWas the event witnessed?YesNoIf yes, by whom?Was CPR performed by bystander prior to AED switch on?YesNoIf yes, for how long?What was the rescuer response time (from SCA to retrieving AED)?Did the patient have a pulse prior to commencing CPR?YesNoUnknownWas the patient breathing prior to commencing CPR?YesNoUnknownWas a shock delivered?YesNoType of Location of Resuscitation AttemptPlease identify the type of location in which the resuscitation attempt occurred.Please select one.*HomeOfficeMedical FacilitySports CenterPublic SpaceOtherUnknownDetails (if unknown, enter N/A)*(For instance, a gym, dentist office, restaurant, park) Please do not provide identifiable information such as place names or addresses.Patient OutcomePlease select one.*Survived to Hospital AdmissionSurvived to Hospital DischargeDid Not SurviveUnknownDetails (if unknown, enter N/A)*Details, such as extra information on resuscitation attempt. (For instance, when did ambulance arrive, what actions were taken, survival beyond hospital admission etc.) Please do not provide identifiable information such as city names, hospital names or addresses.Is the device used available for investigation, if required?*YesNoWas the event downloaded using Saver EVO software?*YesNoIf yes, please upload your event file here (.evo file).Accepted file types: evo.If no, should HeartSine provide a printed or download version of the event?*Printed versionDownloaded versionNeitherForward HeartsHas the survivor been informed of the HeartSine Forward Hearts program? (http://heartsine.com/forward-hearts/)YesNoDoes the survivor wish to participate in the Forward Hearts program?YesNoAdditional Comments/SuggestionsTERMS: Following are the terms for the Free Pad-Pak and Forward Hearts programs. 1. The event must be an actual sudden cardiac arrest to qualify. 2. The event is verified by the HeartSine Clinical Team, whose decision is final. 3. Exclusions apply. Please contact your sales representative for details. 4. Please do not attach any picture, audio and/or video recording related to the reported event. 5. The person completing this form will ensure compliance with local privacy regulations, and agrees to ensure no identifiable information is contained in this form. Please read our privacy statement.
