Butte School District

Noninstructional Operations

Name of person completing report: ________________________________________________________

Date report is being completed: ______________________ Date of Incident: ______________________

Name of patient on which AED was applied: __________________________________ Age __________

Known status of patient

Student

Parent of Student

Other, explain _______________________________________

Describe incident: _____________________________________________________________________

____________________________________________________________________________________

List series of events from the start of the emergency until its conclusion: __________________________

_____________________________________________________________________________________

Your Signature: _____________________________________________

Please forward to the Superintendent of Schools no later than forty-eight (48) hours after the incident.