1. Please check the box if you would like to receive information about new products or specials by e-mail. Yes
2. Date of incident
3. Patient age
4. Patient weight (pounds or kilograms)
5. Patient location? (home, store, airport, etc.)
6. Did any bystanders perform CPR? Yes No Unknown
7. What type of care provider used the FR2+? (i.e. EMT, First Responder, Police)
8. Estimated time from collapse to pads applied:
9. Were any shocks delivered? Yes No Unknown
10. If yes, how many?
11. What is the estimated time from collapse to first shock?
12. Was defibrillation successful (as seen by ECG or return of pulse)? Yes No Unknown
13. Did the patient have return of spontaneous circulation (ROSC)? Yes No Unknown
14. In your opinion, was the device easy to use? Yes No
15. If not, please provide suggestions for how the device, its instructions, lableling, video, etc. could be improved.
16. Were there any problems that you noted regarding the operation of the device; some examples include loss of power or voice prompts? Yes No
17. If yes, what specifically did not meet your expectations?
18. Do you know if the FDA was contacted regarding the use? Yes No
19. Was the patient admitted to the hospital?
20. Did the patient survive to hospital discharge? Yes No Unknown
21. Please briefly describe incident.
22. Was the patient treated with any other defibrillator? Yes No Unknown
23. If yes, please briefly describe treatment.
