Customer Event 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 InformationGender*MaleFemaleNon-Binary/Third GenderAge in Years*Weight (Estimation)(Please indicate Lb or Kg)Event InformationCountry*Date of Use* Date Format: MM slash DD slash YYYY Time of Use (Local)Was the event witnessed?YesNoIf yes, relationship to patient?Was CPR performed by bystander prior to AED switch on?YesNoIf yes, for how many minutes?What was the rescuer response time, in minutes (from SCA to retrieving AED)?Was patient breathing prior to commencing CPR?YesNoUnknownDid the patient have a pulse prior to commencing CPR?YesNoUnknownWas a shock delivered?YesNoLocation Type for Resuscitation AttemptPlease select one.*HomeOfficeMedical facilitySports centerPublic spaceOther (Describe location, without name or geographical location)UnknownDetails (if unknown, enter N/A)*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 OutcomeOutcome (Please select one.)*Survived to Hospital AdmissionSurvived to Hospital DischargeDid Not SurviveDetails (if unknown, enter N/A)*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)Condition Diabetes Mellitus Hypertension Hyperlipidaemia Implanted Pacemaker Please check all that apply.Please list other known conditions.Event fileThe 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.Please upload your event file here (.evo file).Accepted file types: evo.Note: A PDF file will not be accepted.Device InformationDevice Type*SAM 300SAM 300PSAM 350PSAM 360PSAM 450PSAM 500PPDU 400Device Serial Number*Pad-Pak InformationPad-Pak Type*Pad-PakPediatric-PakPad-Pak Lot/Serial NumberPad-Pak Expiration DateReporter InformationEvent Reporter Name*TelephoneEmail* Distributor NameUser InformationWas user trained? (if known)YesNoTraining Provider (if known)TermsFollowing 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. Additional 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.
