AED QUESTIONNAIRE

Name of agency, company, or organization:

Date:
Contact Person :
Phone number :
Address :
Organizations with AEDs:
How many AEDs are currently in place?
What brand of AED do you have ?
When did you purchase the AED?
Are your AEDs in a secured or unsecured area? Secured area Unsecured area
Are your AEDs checked on a daily, weekly, or monthly basis? Daily Weekly Monthly
Who provides annual or bi-annual biomedical checks?
Number of trained in AHA CPR at your organization:
Who is your current medical director?
Organizations Seeking to Purchase AEDs:
Who will be your medical director?
How many AEDs are you planning to obtain?
What brand do you plan to buy?
When were you planning to purchase an AED?
Where do you plan to place it?
Who will do your annual or bi-annual AED checks?
Will you check it on a daily or weekly basis? Daily Weekly
Will it be placed in a secured or unsecured area? Secured area Unsecured area
Do you have any staff currently AHA CPR trained? Yes No
If Yes, how many?


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Please mail form to:

La Porte County EMS Department
809 State Street, Suite 301A
La Porte, IN 46350