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CR2 Reportable Issues and Concerns
Use this form to report any issues related to the CR2 AED
*** SAVE THE AED PADS RELATED TO ANY REPORTABLE ISSUE THE MCA WILL COLLECT THE PADS***
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* Indicates required question
Agency Reporting:
*
Your answer
Reported Date:
*
MM
/
DD
/
YYYY
Occurrence Date / Time
*
MM
/
DD
/
YYYY
Time
:
AM
PM
Occurrance Type
*
Concern
FYI / Notification
Other:
Required
Occurrence Location
*
Your answer
Occurrence Address
If Applicable
Your answer
Occurrence Category
*
Delay in care for Cardiac Arrest Patient
Equipment Failure
Other:
Required
Please Desribe Your Event:
*
Your answer
Patient Last Name / First Name
If Applicable
Your answer
Where was the Patient Transported
Borgess Medical Center
Bronson Methodist Hospital
No Transport
Other:
Agency(s) Involved
*
Your answer
Personnel Involved
*
MFR
EMT
Paramedic
Nurse
Physician
Dispatcher
Other:
Required
Extenuating Circumstances / Field Conditions
*
Your answer
Desired Outcome
*
Your answer
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