The 8452 F1 form serves a critical function within schools, particularly for Upper Sandusky Exempted Village Schools, by meticulously documenting the use of Automated External Defibrillators (AEDs) during incidents of Sudden Cardiac Arrest (SCA). This comprehensive form captures essential information, starting with the patient's age, sex, and date of birth, crucial for providing context to the medical emergency. It requires the recording of the date and specific location where the SCA occurred, which is vital for analyzing the circumstances and potentially improving future response strategies. The form also asks whether CPR was initiated before AED application and if the cardiac arrest was witnessed, including the identity of the witness, if applicable. Detailed documentation continues with the estimated time of the SCA, using the precise 24-hour military format, followed by a record of the number of shocks delivered, specifying the time and the joules for each. The form inquires whether data were successfully downloaded to a Medtronic device and if EMS downloaded the information, ensuring a thorough data collection process for medical analysis. Additionally, a brief narrative section allows for a more detailed account of the incident, offering insights not covered by the form's structured fields. Lastly, the person completing the form is required to provide their name and the date, adding a layer of accountability and traceability to the report. Issued in January 2006, this document plays a pivotal role in managing and reviewing AED interventions in school settings, highlighting the importance of structured emergency response documentation.
| Question | Answer |
|---|---|
| Form Name | Form 8452 F1 |
| Form Length | 1 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 15 sec |
| Other names | Exempted, AED, SCA, F1 |
8452 F1/Page 1 of 1
Upper Sandusky Exempted Village Schools
Automated External Defibrillator (AED) Use Report
Patient Age: |
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Patient Sex: |
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Date of Birth: |
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□ Male |
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□ Female |
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Patient Name: |
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Date of Incident (Sudden Cardiac Arrest- SCA): |
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Location of Sudden Cardiac Arrest (SCA): |
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Estimated Time of Sudden Cardiac Arrest (Use 24 hour Military Time): |
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CPR Initiated Prior to Application of AED? |
□ YES |
□ NO |
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Sudden Cardiac Arrest Witnessed? |
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□ YES |
□ NO |
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If yes, by whom: |
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First Shock Delivered |
Second Shock Delivered |
Total Number of Shocks |
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(Use 24 Hour Military |
(Use 24 Hour Military |
and Joules Delivered: |
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Time): |
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Time): |
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Data Downloaded to |
Data Downloaded by |
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Medtronic? |
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EMS? |
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□ YES |
□ NO |
□ YES |
□ NO |
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Brief Narrative:
Name of Person Completing this Form: ___________________________________________
Date:_______________________________________________________________________________
January 2006