ࡱ> 685S y!bjbj A(vtivti <^^^^^rrr8,rt(bbb2444444$o%`X]^bbbbbX^^HbF^^2b25<,j0^DbbbbbbbXXbbbbbbbbbbbbbbbbX $: Confidential Appendix A - AED Post-Incident Report Confidential Incident Details Date: ______________________________________ Time of Incident: _____________________________ Location (Building/Room): _________________________________________________________________ Activity engaged in when incident occurred: ___________________________________________________ Personnel responding (list): ________________________________________________________________ _______________________________________________________________________________________ Witnesses (list): __________________________________________________________________________ 911 called? Yes No Estimated time: _________________________________ Rescue breathing performed? Yes No Estimated start time: _______________________ CPR performed? Yes No Estimated start time: _____________________________ AED used? Yes No Estimated start time: _____________________________ Shocks delivered: Yes No AED Make/Model: _____________________________________________ Result: _________________________________________________________________________________ _______________________________________________________________________________________ Any additional injuries: ____________________________________________________________________ Other equipment utilized: __________________________________________________________________ Patient Details: This information is to remain confidential except for purposes of completing this report. Last Name: ___________________ First Name: ______________________Middle____________________ Faculty Staff Student Visitor Event Details Lead responder: __________________________________________________________________________ EMS scene arrival: ______________________ Patient transported to: _______________________________ Comments: _____________________________________________________________________________ _______________________________________________________________________________________ If the caregiver was exposed to blood or other infectious materials, immediately notify UNC Pembroke Environmental Health and Safety and seek medical care. C  %&579:EFG꬘p\K7'h3h}5B*CJPJ\aJph h3h}CJOJQJ^JaJ&hVch}5CJOJQJ\^JaJ&hVch5CJOJQJ\^JaJ&h3h35CJOJQJ\^JaJ&h3h}5CJOJQJ\^JaJ)hVchVc5CJOJQJ\]^JaJ&h3h5CJOJQJ\^JaJ)hVch5CJOJQJ\]^JaJ)hVch}5CJOJQJ\]^JaJFGY r P ` 6F2Pedh1$]^gd}dh1$@&]^gd}$a$gd3GXYv  Y d r P ( , 8 < n @ L ` $ ( 4 8 | "6mx$ոոոոոոոոոո%h'ph}B*OJPJQJ^Jphh}B*PJphh'ph}B*PJphh3h}B*PJphh3h}5B*PJ\phH$FozRZ2NPOZe mpqry ˻򒃁Uhh}5B*PJphh}5B*PJphh3B*PJph%h'ph}B*OJPJQJ^Jphh'ph}6B*PJ]phh}5B*PJ\phh'ph}5B*PJ\phh}B*PJphh'ph}B*PJph-e[ \ !?!A!B!D!E!G!H!I!J!K!L!M!N!q!r!$a$1$]^gd}1$]^gd}m$dh1$]^gd}ompleted by: ____________________________ Date: ________________ Phone: _________________ AED Incident Report Notification --Within 24 hours of incident or next business day forward this report to the UNC Pembroke Environmental Health and Safety Office (910) 521-6792, and Student Health Services (910) 521-6219.     Page  PAGE 1 of  NUMPAGES 1 Y [ \ |  :!;!!?!@!A!B!C!D!E!F!G!H!I!J!K!L!M!N!S!T!Z![!\!]!a!b!m!n!o!p!ȹzszgzzszgzh:5\mHnHu h35\jh35CJU\aJh3hyjhyUh7h'ph}B*PJphh'ph}B*PJ\phhVh}B*PJ\phh}5B*PJ\phh'ph}5B*PJ\phh}5B*PJphh'ph}5B*PJph(p!q!r!s!t!u!v!w!x!y!h7hyh3 r!s!t!u!v!w!x!y!1$]^gd}?0P1h:p6E/ =!"#$% Dpx666666666vvvvvvvvv666666>6666666666666666666666666666666666666666666666666hH6666666666666666666666666666666666666666666666666666666666666666662 0@P`p2( 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p8XV~ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@66666 OJPJQJ_HmH nH sH tH X`X }Normal1$7$8$H$$CJOJPJQJ_HaJmH sH tH DA D Default Paragraph FontRiR 0 Table Normal4 l4a (k ( 0No List bob }Default 7$8$H$-B*CJOJQJ^J_HaJmH phsH tH X@X }0HeaderH$1$7$8$H$CJOJPJQJ^JaJ.. }0 Header CharX @"X }0FooterH$1$7$8$H$CJOJPJQJ^JaJ.1. }0 Footer CharPK![Content_Types].xmlN0EH-J@%ǎǢ|ș$زULTB l,3;rØJB+$G]7O٭Vj\{cp/IDg6wZ0s=Dĵw %;r,qlEآyDQ"Q,=c8B,!gxMD&铁M./SAe^QשF½|SˌDإbj|E7C<bʼNpr8fnߧFrI.{1fVԅ$21(t}kJV1/ ÚQL×07#]fVIhcMZ6/Hߏ bW`Gv Ts'BCt!LQ#JxݴyJ] C:= ċ(tRQ;^e1/-/A_Y)^6(p[_&N}njzb\->;nVb*.7p]M|MMM# ud9c47=iV7̪~㦓ødfÕ 5j z'^9J{rJЃ3Ax| FU9…i3Q/B)LʾRPx)04N O'> agYeHj*kblC=hPW!alfpX OAXl:XVZbr Zy4Sw3?WӊhPxzSq]y , ( 79;>G$ p!y! er!y!  %13>!T # @ 0(  B S  ?H0(   * -  * - 333%&457:EEpqry      # -  -   6EVcdGyy}:37W @FFFFX, @ @  $@ @@UnknownG.[x Times New Roman5Symbol3. .[x Arial7..{$ CalibriC.,.{$ Calibri LightA$BCambria Math"hJ'MZ'{t{t20 K@P  $P}2!xx1:&z  UNC PembrokeMichael Bullard Oh+'0d   , 8DLT\UNC PembrokeNormalMichael Bullard3Microsoft Office Word@G@>(>%<,{t ՜.+,0 hp  UNC Pembroke   Title  !"#$&'()*+,./012347Root Entry F 5<,91TableWordDocumentA(SummaryInformation(%DocumentSummaryInformation8-CompObjr  F Microsoft Word 97-2003 Document MSWordDocWord.Document.89q