Trinity University
Environmental Safety Office
Box 61
Margaret Parker Chapel, Rm. 102
Date of incident: __________________________________ Time of Incident: ____________ am pm
Name and contact information of victim – if known: __________________________________________
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Name and contact information of person(s) who found the victim: ________________________________
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Name and contact information of person(s) who determined the victim was unresponsive: _____________
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Name and contact information of person(s) who operated the AED: _______________________________
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Did the victim have a pulse? Yes No How was the pulse checked?_______________________
Was the victim breathing? Yes No How was the breathing checked? ___________________
Was EMS called (911)? Yes No If yes, what time did that happen? __________________
Briefly describe the incident that resulted in the AED being brought to the victim:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
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Was the AED applied to the victim? Yes No How many times was the victim defibrillated? ________
Status of Patient at the time EMS personnel arrived?
Did the victim have a pulse? Yes No How was the pulse checked? _____________________
Was the victim breathing? Yes No How was the breathing checked? _________________
Form Completed by: _____________________________________Date signed: ___________________
Signature: ______________________________________________
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Campus A.E.D. Locations: |
Campus A.E.D. Locations:
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| Marrs-McLean 1st Floor Lobby | Northrup Hall 1st Floor Foyer |
| Chapman 1st Floor | Holt Center 1st Floor (near elevator) |
| Cowles Life Sciences 2nd Floor | Coates University Center Foyer |
| Dicke Art/Smith Music 1st Floor Lobby | Admissions 1st Floor Lobby |
| Halsell Bldg 1st Floor | Laurie Auditorium 3rd Floor East (near elevator) |
| Moody Engineering 1st Floor | Coates Library 3rd Floor (near Circulation Desk) |
| Storch 1st Floor | Physical Plant Garage |
| Stieren Theater 2nd Floor | Mabee Dining Hall 1st Floor |
| D.C.S. Patrol Vehicle | Bell Center Outside Student Desk |
| Environmental Safety Office | Bell Center Athletic Trainers |