AED Authorization

Automatic External Defibrillator (AED) Authorization Form

AED Authorization Form Type

AED Owner

Provide information of the Department that own the AED unit
Chair/Director Name
Department Address

Primary Department Coordinator

List the primary contact responsible of the AED unit
Name(Required)
Address(Required)

Alternate Department Coordinator

List alternate contacts responsible of the AED unit
Name(Required)
I want this contact person to receive AED notifications
Name
I want this person to receive AED notifications

AED Identification

Provide information of the AED unit
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Training Certification

Department coordinator is highly encouraged to provide appropriate training to each user. Training in CPR & AED
Name
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Name
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Name
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Quality Assurance Program

Provide information of your communication plan and preventative maintenance program
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)
Type of reporting
Frequency
Program Updates

Acknowledge

By signing below, I certify that this information is true and correct toe h best of my knowledge.
Primary Coordinator Name(Required)
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Department/Chair Name
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