Event Satisfaction Survey Form

Report of the use of the LifeVac device

We understand that choking is a very scary experience, both for the victim and those witnessing and/or helping to try to remove an airway obstruction. We hope that everything turned out well in this situation and that you will take a few minutes to tell us about your experience.
Date of the incident *

Day Month Year
Date
Location of the incident

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Age of the choking person? *
Name of choking person? (optional and not for print)

First Name Last Name
Did the person have any relevant pre-existing health problems? (Please specify)
If "none" just write NONE
What type of material did the person choke on? *
What type of obstruction was it? *

Complete obstruction (silent and couldn't cough effectively) Incomplete or partial obstruction (could cough effectively) Unknown
Which first aid measured attempted before using LifeVac? *

Back blows Chest Thrusts Abdominal Thrusts CPR None of the above
Was the choking person conscious when the LifeVac was used? *
Number of times the LifeVac was operated? i.e. place-push-pull sequences *
What was the outcome of using the LifeVac device? *
Do you believe the LifeVac assisted in the management of the choking person? *

Yes No Unsure
Was there any medical follow-up of the person and if so what was the result ? *
If 'None" just write NONE
Name so we can send you a free LifeVac?

First Name Last Name
Phone Number

Area Code Phone Number
Email
example@example.com.au
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
How did you hear about the LifeVac?
How can we improve your experience with the LifeVac?
Please verify that you are human *
Should be Empty:

Report of the use of the LifeVac device