Customer Event Report Form

  • FORM MUST NOT CONTAIN INFORMATION THAT COULD IDENTIFY THE PATIENT Please do not provide any identifiable information, such as patient name, address or location of hospital.
  • Patient Information

  • (Please indicate Lb or Kg)
  • Event Information

  • Date Format: MM slash DD slash YYYY
  • Location Type for Resuscitation Attempt

  • Please indicate the specific type of location (gym, dentist office, restaurant, etc.), providing as much information as possible. DO NOT PROVIDE PLACE NAME, ADDRESS OR GEOGRAPHICAL LOCATION.
  • Patient Outcome

  • Please provide any additional information on rescue attempt (when did ambulance arrive, actions taken). DO NOT PROVIDE CITY, OR HOSPITAL NAME OR ADDRESS. Please do not provide identifiable information such as city names, hospital names or addresses.
  • Patient Pre-Existing Medical Condition (if known)

    Please check all that apply.
  • Event file

    The event file, downloaded using SAVER EVO software, must be uploaded with this form. Please use the following filename structure: Device serial number_Date of event (MM-DD-YYYY). If you need assistance downloading the file, please contact heartsinesupport@stryker.com.
  • Accepted file types: evo.
    Note: A PDF file will not be accepted.
  • Device Information

  • Pad-Pak Information

  • Reporter Information

  • User Information

  • Terms

    Following are the terms for the Free Pad-Pak and Forward Hearts programs. 1. Please do not attach any picture, audio and/or video recording related to the reported event. 2. Event must be a sudden cardiac arrest to qualify. (Event is reviewed by Stryker Clinical team whose decision is final.) 3. Please refer to heartsine.com for the complete list of requirements to qualify for Free Pad-Pak and/or Forward Hearts after a Stryker AED has been used during a sudden cardiac arrest resuscitation. 4. The person completing this form will ensure compliance with local privacy regulations, and agrees to ensure no identifiable information is contained in this form.
  • TERMS: 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.

 

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