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To help us continually improve training and products.
Please print out and fill in this form after using your TXO2® AUTOMATED First Aid Oxygen unit.
This form can be mailed or faxed to the above contact information, or to your distributor.

Victim's name (optional) ______________________________________________________

Approximate age ________

o Male
o Female

Family Dr.:_______________________________

Phone #:_________________________________

Suspected cause for using TXO2
o Cardiac Arrest
o Choking
o Heart Attack/Chest Pain
o Breathing Problem
o Injury/Burns
o Passed out
o Seizure
o Diabetic
o Stroke
o Pool
o Water Rescue

OTHER:_________________________________

NOTES:

EMS SERVICE that responded _______________________________________________________

Victim transported to _______________________________________________________________

Final Diagnosis (if known)____________________________________________________________

Outcome (if known)_________________________________________________________________

Person(s) who rendered care (optional)_________________________________________________

Your Facility Name _________________________________________________________________

Address___________________________________________________________________________

Phone________________________ FAX________________________

Person filling out report (optional)_______________________________________________________

Was there any problems encountered in administering TXO2 to the victim? ____________________

NOTES:

o AED available

AED used: shocked #________ times

Request verbal discussion of events with emergency medical professional (Debriefing)__________

DATE of use_____________

TIME (approx.)___________

Amount of O2 used______ minutes

How long has the TXO2 unit been available at the location where used?__________________________

REMEMBER: CALL YOUR DISTRIBUTOR IMMEDIATELY for refills.
THANK YOU!

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