AED Inspection Form AED Inspection Please indicate the below information with the condition that you are leaving the AED with – for example, if you’ve replaced pads or battery, indicate the new expiration date for these items. This form is automatically emailed to the on-site contact for the AED unit so that they have a record of the information.Person Completing Inspection:* Business / Organization:*On Site Contact:*Phone:*Email* Address of AED Location* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Location of AED at Address:*AED Brand:*SelectCardiac ScienceDefibtechHeartSinePhilipsPhysio-ControlZollOtherOther AED Brand:*Be as specific/descriptive as possible. Powerheart AED G3 Plus Powerheart AED G3 Pro(Has ECG Screen) Powerheart AED G5 Cardiac Science Model:*SelectPowerheart AED G3 PlusPowerheart AED G3 ProPowerheart AED G5 Defibtech Lifeline Defibtech View(Has ECG Screen) Defibtech Model:*SelectDefibtech LifelineDefibtech View Heartsine Samaritan 350P & 450P HeartSine Models*SelectHeartSine 350PHeartSine 360PHeartSine 450P Heartstart OnSite AED Heartstart FRX HeartStart FR3 Philips Models*SelectHeartstart OnSite / HomeHeartstart FRxHeartstart FR2 / FR2+Heartstart FR3Heartstart Forerunner Lifepak Express AED Lifepak CR Plus Lifepak 1000 Physio-Control Models*SelectLifepak CR PlusLifepak ExpressLifepak 500Lifepak 1000Lifepak CR2 Zoll AED Plus Zoll AED Pro Zoll Models*SelectAED PlusAED ProAED Serial NumberDoes AED have 3-Dimensional Signage?*A 3D sign is a triangular marker on the wall above the AED so that its location can be seen from either direction. Yes No Is AED accessible at all time that the building is occupied?*If kept in a locked office, select “No” Yes No Is AED kept in a wall mounted cabinet?* Yes, cabinet is alarmed Yes, cabinet is not alarmed No, but AED is attached to a wall No Does AED have a carrying case?* Yes No Does AED have a rescue kit?*If not attached to AED, please attach it if possible and indicate that it is attached to the AED. Yes, and rescue kit is attached to AED Yes, but it is not attached to AED No rescue kit Does rescue kit include each of the following items?*-Gloves -Gauze or Towel -CPR Pocket Mask or Barrier -Razor -Scissors or shears Yes, rescue kit is fully stocked No, rescue kit is missing items What is missing from rescue kit?*Adult Pads Expiration Date:* MM slash DD slash YYYY Backup Adult Pads Expiration Date: MM slash DD slash YYYY Pediatric Pads Expiration Date: MM slash DD slash YYYY Battery Date: MM slash DD slash YYYY AED is ready for use:*Cardiac Science AEDs Yes: Rescue Ready indicator is green No: Rescue Ready indicator is red AED is ready for use:*Defibtech AEDs: Yes: Indicator light is green No: Indicator light is red No: Indicator light does not flash AED is ready for use:*HeartSine AEDs: Yes: Status Indicator flashes green No: Status Indicator flashes red No: Status Indicator not flashing AED is ready for use:*Philips AEDs: Yes: Status Indicator flashes green No: Status Indicator flashes red No: Status Indicator not flashing AED is ready for use:*Physio-Control AEDs: Yes: LCD screen reads “OK” No: LCD screen does not indicate “OK” No: LCD screen is blank AED is ready for use:*Zoll AEDs: Yes: Device displays green check No: Device displays red X AED is ready for use:* Yes: Status Indicator flashes green No: Status Indicator flashes red No: Status Indicator not flashing Device Notes:
