AED Authorization

Automatic External Defibrillator (AED) Authorization Form
AED Authorization Form Type
- New Registration
- Status Update
AED Owner
Provide information of the Department that own the AED unit
Department(Required)
Chair/Director Name
First Last
Title
Department Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Phone
Email
Primary Department Coordinator
List the primary contact responsible of the AED unit
Name(Required)
First Last
Title
Address(Required)
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Email(Required)
Phone(Required)
Alternate Department Coordinator
List alternate contacts responsible of the AED unit
Name(Required)
First Last
Title
Email(Required)
Phone(Required)
I want this contact person to receive AED notifications
- Enable Notifications
Name
First Last
Title
Email
Phone
I want this person to receive AED notifications
- Enable Notifications
AED Identification
Provide information of the AED unit
Date unit was purchased(Required)
MM slash DD slash YYYY
Date unit was installed
MM slash DD slash YYYY
AED Location (provide a description(Required)
Building(Required)
Room Number(Required)
Floor Number(Required)
Manufacturer(Required)
Model(Required)
Serial Number(Required)
Battery Expiration Date(Required)
MM slash DD slash YYYY
Spare Battery Expiration Date
MM slash DD slash YYYY
Adult Pads Expiration Date(Required)
MM slash DD slash YYYY
Spare Adult Pads Expiration Date
MM slash DD slash YYYY
Pediatric Pads Expiration Date
MM slash DD slash YYYY
Spare Pediatric Pads Expiration Date
MM slash DD slash YYYY
Training Certification
Department coordinator is highly encouraged to provide appropriate training to each user. Training in CPR & AED
Name
First Last
Title
Training Expiration Date
MM slash DD slash YYYY
Email
Phone
Name
First Last
Title
Training Expiration Date
MM slash DD slash YYYY
Email
Phone
Name
First Last
Title
Training Expiration Date
MM slash DD slash YYYY
Email
Phone
Quality Assurance Program
Provide information of your communication plan and preventative maintenance program
AED manual(s) and additional information are available at
Describe the communication plan for advising building occupants of the presence and locations(s) of AEDs
Describe how internal notification of an emergency, including how AED Responders will be contacted
Event Tracking/Reporting - Upon use the EMS system must be notified promptly. Person responsible for notification UFPD and EHS
Per manufacturer's guidelines, must be maintained and tested. Preventative maintenance (PM) procedures that check the status of the battery, the condition and expiration of the padsd as well as other items that may be specified by the manufacturer. These items should be checked a minimum of monthly basis or based on manufacturer's recommendation.
Name(Required)
First Last
Title
Type of reporting
- Written
- Online
- Both
Frequency
- Daily
- Weekly
- Monthly
Program Updates
- Review and update of this program will be performed annually by the AED Department Coordinator and report to EHS if update is needed.
Acknowledge
By signing below, I certify that this information is true and correct toe h best of my knowledge.
Primary Coordinator Name(Required)
First Last
Signature(Required)
Date(Required)
MM slash DD slash YYYY
Department/Chair Name
First Last
Signature
Date
MM slash DD slash YYYY
Phone
This field is for validation purposes and should be left unchanged.

AED Authorization

Automatic External Defibrillator (AED) Authorization Form

AED Owner

Primary Department Coordinator

Alternate Department Coordinator

AED Identification

Training Certification

Quality Assurance Program

Acknowledge

Resources

Campus

Website

UF Environmental Health and Safety

UF Environmental Health and Safety

AED Authorization

Automatic External Defibrillator (AED) Authorization Form

AED Owner

Primary Department Coordinator

Alternate Department Coordinator

AED Identification

Training Certification

Quality Assurance Program

Acknowledge

Resources

Campus

Website