Emergency Report  ·  Pro

Capture Every Step of a Cardiac Arrest & AED Response

Log cardiac arrest emergencies at your gym with timed CPR, AED and EMS milestones, responder certifications, outcomes and uploaded AED event data.

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formbuilder.ai/f/fitness-center-member-cardiac-arrest-aed-emergency-response-report-form
Fitness Center Member Cardiac Arrest & AED Emergency Response Report Form
Date of Incident
· · ·
Approximate Time of Collapse
· · ·
Location Within Facility
Submit

The Fitness Center Member Cardiac Arrest & AED Emergency Response Report Form gives your staff a structured way to document one of the most serious events a facility can face. It captures the key incident details: the date, approximate time of collapse, location within the facility, the affected individual's name and status, what they were doing when they collapsed and whether the collapse was witnessed. A dedicated response section records exactly when 911 was called, CPR was started, AED pads were applied and EMS arrived. It also logs the number of shocks delivered, the AED unit deployed (cabinet location and serial number) and each responder's name, role and CPR/AED certification status.

This template is built for gym owners, fitness center managers, health club operators, recreation centers, corporate wellness facilities and safety officers who need reliable post-incident documentation. Staff can note the individual's condition and transport status at EMS handoff and write a detailed narrative of events from collapse to handoff. They can also upload supporting files such as AED event data, witness statements and photos.

A consistent digital report helps you build an accurate timeline while details are still fresh. It supports insurance and liability reviews and makes it easier to share information with emergency medical services and management. Reviewing completed reports can also reveal gaps in response times, AED placement and staff certification. That helps you strengthen your emergency action plan and better protect your members. Customize the fields to match your facility's protocols and start collecting complete, organized reports today.

3 Pages
21 Questions
~7min To complete
Free Included on every plan
Field types Time Picker ×5 Dropdown ×3 Full Name ×2 Single Choice ×2 Long Text ×2 Date number Short Text File Upload Multiple Choice termsandconditions Signature

Questions in this template

Free template

The exact questions included — customize any of them to fit your needs.

Page 1 Incident & Individual Details 7 questions
Incident & Individual Details
1 Date of Incident * Date
2 Approximate Time of Collapse * Time Picker
3 Location Within Facility * Dropdown
4 Name of Affected Individual * Full Name
5 Individual's Status * Single Choice
6 Activity at Time of Collapse * Dropdown
7 Was the Collapse Witnessed? * Single Choice
Page 2 CPR, AED & EMS Response 7 questions
CPR, AED & EMS Response
1 Time 911 / EMS Was Called * Time Picker
2 Time CPR Was Started * Time Picker
3 Time AED Pads Were Applied Time Picker
4 Time EMS Arrived on Scene * Time Picker
5 Number of AED Shocks Delivered (Enter 0 if None) * number
6 AED Unit Deployed (Cabinet Location & Serial Number) * Short Text
7 Responders On Scene (Names, Roles & CPR/AED Certification Status) * Long Text
Page 3 Outcome, Follow-Up & Certification 7 questions
Outcome, Follow-Up & Certification
1 Individual's Condition & Transport Status at EMS Handoff * Dropdown
2 Detailed Incident Narrative (Sequence of Events From Collapse to EMS Handoff) * Long Text
3 Supporting Documents (AED Event Data, Witness Statements, Photos) File Upload
4 Post-Incident Actions Completed * Multiple Choice
5 Report Completed By * Full Name
6 I certify that the information in this report is accurate and complete to the best of my knowledge, and I understand it is a confidential document used for incident review, AED program oversight, and legal or insurance purposes. * termsandconditions
7 Reporter Signature * Signature

How to use this template

Click "Use This Template Free" to open it in the FormBuilder editor. From there you can add, remove, or reorder fields with drag-and-drop, switch themes for instant restyling, add your logo, configure email notifications, and set your success message. When ready, publish with a unique link and start collecting responses immediately.

  • Ready-to-use structure — pre-configured fields out of the box
  • Applied "Volt" theme — fonts, colors, and layout already set
  • Mobile-responsive — works on every device without extra configuration
  • Fully editable with drag-and-drop — change anything in seconds
  • Included on every plan — try it free for 7 days

Use this template

Included on every plan. Open in the editor, customize, and publish in minutes.

Use This Template Free Preview the form
Category Report & Incident
Subcategory Emergency Report
Theme Volt
Badge Pro
Price Free
Coding required None

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