PUBLIC ACCESS AED USE REPORT

This confidential form needs to be completed immediately following an emergency when AED pads have been applied to a person, even if no shocks were delivered. This form data will be sent to the Maryland Institute for Emergency Medical Services Systems (MIEMSS) to maintain the quality of Maryland's AED program. 

 

 

Date and Time of AED Use

 
 
mm/dd/yyyy
 
 
 
 

 

Location Information

 

Please select from the list below.

 
 

Please include City / State

 

 

Patient Information

 
 

Leave blank if unknown

 
 
 

 

Care Information

 
 
 
 
 
Drop your files here
 

 

Contact Information

This information may be used if additional information is needed.

 
 
 
 
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