Contact person responsible for the product(s)
(to whom product notices and updates will be sent)
First Name
Last Name
Title
Company
Phone Number
Fax
Email
Serial Number of device used in rescue:
Models (select all that apply)
ARM-XR Series
ARM-XR Series
Serial Number
Must be 9 digits and begin with a 5.
Performance of Device
Deployment No Flow Time (time of any CPR interruption):
Was ROSC (Return of Spontaneous Circulation) established:
Yes
No
Unsure
For how long was ROSC sustained?
Please provide any additional detail regarding device performance:
Safety of Device:
Rib fractures:
Yes
No
Unsure
Bruising / Soft Tissue Injury:
Yes
No
Unsure
Liver Rupture:
Yes
No
Unsure
Pneumothorax:
Yes
No
Unsure
Esophagus Hematoma:
Yes
No
Unsure
Intracranial air embolism:
Yes
No
Unsure
Other side effects:
Yes
No
Please provide detailed description of any side effects:
Patient Follow-Up Information:
ED Outcome:
Died in the ED
Admitted to hospital
Unknown
Was patient discharged from hospital?
Yes
No
Unknown
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