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AED Authorization

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    • 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
    MM slash DD slash YYYY
    MM slash DD slash YYYY
    MM slash DD slash YYYY
    MM slash DD slash YYYY
    MM slash DD slash YYYY
    MM slash DD slash YYYY
    MM slash DD slash YYYY
    MM slash DD slash YYYY

    Training Certification

    Department coordinator is highly encouraged to provide appropriate training to each user. Training in CPR & AED
    Name
    MM slash DD slash YYYY
    Name
    MM slash DD slash YYYY
    Name
    MM slash DD slash YYYY

    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)
    MM slash DD slash YYYY
    Department/Chair Name
    MM slash DD slash YYYY

    University of Florida
    Gainesville, FL 32611
    (352) 392-3261

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