Report PAD Use

Report AED Use

Please fill out the Notice of AED Use by PAD Form (click here) and send to:
SWREMSCO c/o Southern Tier Health Care System Inc.
ATTN: PAD Program
150 North Union Street
Olean, NY 14760
[email protected]

OR Fill out the following form to submit information online:

Notice of AED use by PAD

* Indicates required field

Name of PAD Site *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Location of Incident at PAD Site *

Date of Incident *

Time of Incident *

Age of Patient *

Was the Arrest Witnessed? *

Yes No

Time from Arrest to CPR (in minutes) *

CPR Initiated by *

Bystander Staff Other

Number of Shocks by PAD Agency *

Transporting Ambulance Service *

Hospital Transported to *

Patient's Cardiac Outcome on Scene *

Regaining Pulse Remained Pulseless

Patient's Consciousness on Scene *

Became Responsive Remained Unresponsive

Name of Emergency Health Care Physician *

Email *

Submit