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i l - <br /> Simpson Strong-Tie <br /> EAP-FPP Program <br /> MEDICAL EMERGENCY REPORT <br /> Forward this report to Dave Olney and Tony Cervantez <br /> A) The following is to be filled out by the person who discovered the medical emergency. <br /> Date Time of Emergency am / pm <br /> Person Who Reported Emergency <br /> Nature of the Emergency? (fracture,heart-attack,etc.) <br /> Was a First-Aider/CPR Qualified Individual Called? <br /> Who Responded? (First-Aider/CPR Qualified Individual) <br /> Who Required Medical Attention?(customer,employee,visitor) <br /> Describe What happened (when did you notice the problem,what did you notice,who did you notify,etc.) <br /> B) The following is to be filled out by the reporting individual, and/or the Emergency <br /> Situation Coordinator. <br /> Time 911 was Notified? am / pm Response Time <br /> Person Who Notified 911 <br /> Nature of the Emergency <br /> Did a First-Aider/CPR Qualified Individual Respond? Yes_ No <br /> Was First-Aid/CPR Administered by the Qualified Individual? Yes_ No <br /> How was the First-Aider/Qualified Individual Notified? (phone call,messenger,alarm,etc.) <br /> What medical supplies were used in the response? <br /> Who was the medical emergency for?(customer,employee,visitor) <br /> (Individual's Name) (Phone Nurobe , <br /> Where was the Person Taken? rt <br /> Person Filling Out Report <br /> (Name) (Phony Number) <br /> R` U-' <br /> David Olney 7 <br /> Rev: 9/17/15 <br />