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)

Date unit was installed

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)

Spare Battery Expiration Date

Adult Pads Expiration Date(Required)

Spare Adult Pads Expiration Date

Pediatric Pads Expiration Date

Spare Pediatric Pads Expiration Date

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

Email

Phone

Name

First Last

Title

Training Expiration Date

Email

Phone

Name

First Last

Title

Training Expiration Date

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)

Department/Chair Name

First Last

Signature

Date

Comments

This field is for validation purposes and should be left unchanged.

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