Electrode Data

Date of Report (mo/day/yr):

1. ID Number:
2. Institution:
3. Implant Date (mo/da/yr):
4. Manufacturer:
5. Model Number:
6. Electrode Serial Number:
7. Is this the patient's first electrode: (select if YES)
8. Site of Implant: atrium ventricle (pick one)
9. Type of electrode: epicardial endocardial (pick one)
10. Electrode was: Used Redundant Retired (pick one)

11. Thresholds at date of reporting:

At Set Pulse Width of: ------ ------ ------ ------

Voltage: ----------------------- ------ ------ ------

Current: ----------------------- ------ ------ ------

12. Resistance measured at 5 volts and 0.5 ms pulse width:

13. Sensing Parameters:

RS amplitude:

Peak to peak amplitude:

Slew rate:

14. Circumstances causing electrode testing

Primary Electrode Placement

Cardiac Surgery