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Sudden Cardiac Arrest (SCA)
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Serious Medical Incident Report

Please fill out the following form to help us assist you better
Once we review your submission we will contact you to ask

how we can assist you

* required

Did you... * Required

Perform CPR?

Bring the AED to the person?

Place the AED pads on the person?

Did the AED advise you to provide a shock?

Did the AED shock the person?

N/A, other serious medical incident (with no CPR or AED)

Was the person a * Required

Child

Teen

Adult

Senior

Victim's Relationship to the School * Required

Member of the Public

Staff

Student

Student's guardian

Visitor (contractor, vendor, guest)

Other

Activity at the time of incident * Required

After School

Before School

Eating

Gym Class

In classroom

Recess

Other

N/A

THANK YOU for submitting and being a Heart-Safe School!
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