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 AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest 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.YesNoIs AED accessible at all time that the building is occupied?*If kept in a locked office, select "No"YesNoIs AED kept in a wall mounted cabinet?*Yes, cabinet is alarmedYes, cabinet is not alarmedNo, but AED is attached to a wallNoDoes AED have a carrying case?*YesNoDoes 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 AEDYes, but it is not attached to AEDNo rescue kitDoes rescue kit include each of the following items?*-Gloves -Gauze or Towel -CPR Pocket Mask or Barrier -Razor -Scissors or shearsYes, rescue kit is fully stockedNo, rescue kit is missing itemsWhat is missing from rescue kit?*Adult Pads Expiration Date:* Date Format: MM slash DD slash YYYY Backup Adult Pads Expiration Date: Date Format: MM slash DD slash YYYY Pediatric Pads Expiration Date: Date Format: MM slash DD slash YYYY Battery Date: Date Format: MM slash DD slash YYYY AED is ready for use:*Cardiac Science AEDsYes: Rescue Ready indicator is greenNo: Rescue Ready indicator is redAED is ready for use:*Defibtech AEDs:Yes: Indicator light is greenNo: Indicator light is redNo: Indicator light does not flashAED is ready for use:*HeartSine AEDs:Yes: Status Indicator flashes greenNo: Status Indicator flashes redNo: Status Indicator not flashingAED is ready for use:*Philips AEDs:Yes: Status Indicator flashes greenNo: Status Indicator flashes redNo: Status Indicator not flashingAED is ready for use:*Physio-Control AEDs:Yes: LCD screen reads "OK"No: LCD screen does not indicate "OK"No: LCD screen is blankAED is ready for use:*Zoll AEDs:Yes: Device displays green checkNo: Device displays red XAED is ready for use:*Yes: Status Indicator flashes greenNo: Status Indicator flashes redNo: Status Indicator not flashingDevice Notes:
