Report the use of the LifeVac device

LifeVac is interested in receiving your feedback on the use of our device, regardless of whether it was successful or not in removing the choking obstruction.

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 are willing to take a few minutes to tell us about your experience. Please note, de-identified data will be used in promotion and advertising activities. No personal identifying information about the patient or rescuer will be shared without the express permission of those persons.

Date of the incident

Date

Location of the incident

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Age of the choking person?

Sex of choking person?

Name of choking person? (optional and not for publication)

First NameLast 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?

Which first aid measure/s were attempted before using LifeVac?

What position was the choking person in when the LifeVac was used?

Was the choking person conscious when the LifeVac was used?

Number of times the LifeVac was operated? (i.e. place-push-pull sequences)

Was the obstruction dislodged using the LifeVac device?

Duration of the incident (i.e. choking event until recovery time)

Do you believe the LifeVac saved the life of the choking person?

Was there any medical follow-up of the person and if so what were the findings? (e.g. complications)

If 'None" just write NONE

Your highest level of formal emergency training

What are your thoughts on the experience using the LifeVac device?

Where did you hear about the LifeVac device?

Have you got any previous experience managing a choking incident?

So that we can send you a free replacement LifeVac device (plus any masks used) can you please specify (if known) which mask/s were used (more than 1 can be selected if applicable)

Please enter your name and details below, so we can send the replacement LifeVac and mask/s

First NameLast Name

Phone Number

Area CodePhone Number

Email

example@example.com.au

POSTAL ADDRESS - so we can send replacement LifeVac and mask/s

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

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