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AED Use Report
To be completed when an AED has been used on any NC State University Campus.
Name
*
Name of person who used the AED
First
Last
Contact Phone number
*
Contact Email address
*
University Employee
*
Was person who used the AED a University employee
Yes
No
Type of employee
Faculty
Staff
Student
Building / Location
*
List the location where the AED was used.
Buliding
Location/Room
AED Manufacturer
*
AED Model
*
Responder(s)
*
select all responders to the location
Fire & Life Safety Office
University Police
EMS
Raleigh Fire Department
Raleigh Police
Other(s)
List other responders
Name
This field is for validation purposes and should be left unchanged.