Mechanical CPR Device Utilization Form

Out of hospital cardiac arrest report

Agency Name *

Phone Number *

Agency Contact Name *

Agency Contact Email *

Device Used *

Date of Cardiac Arrest *

Patient Age *

Patient Gender *

Witnessed Arrest *

EMS Initiated CPR *

Manual Compressions Prio to Mechanical Device *

Length of Time Mechanical Device Was Used On Patient *

Mechanical Device Removed Prior to Transfer of Care *

Patient Outcome *

Please submit blacked out PCR with this form *

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