| E-mail Address: * |
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| Physical Address of Site/Facility: |
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| Contact person: |
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| Position: |
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| Phone Number: |
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| Date: |
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| Is there “enhanced” 9-1-1 coverage in the area? |
Yes
No
Undetermined |
| Comments: |
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| Is there clear EMS access to the property? |
Yes
No |
| Comments: |
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| Are their any “horizontal” barriers to gaction? (Examples of this would be crowded hallways, catwalks, secured doorways or work areas that may have potentially hazardous materials as in a manufacturin setting.) |
Yes
No |
| Comments: |
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| Are there any vertical barriers to action? (ie, would an elevator or stairwell have to be used?) |
Yes
No |
| Comments: |
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| Are there any areas that present unique access problems (security access coded doors, etc.?) |
Yes
No |
| Comments: |
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| Are there any environment hazards (ie. Explosive material, onsite moving vehicles, biohazards) or other safety factors that may influence access to an area or the use of an AED? |
Yes
No |
| Comments: |
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| Are there electromagnetic fields, communication devices worn by the intended rescuers, or other hazards that could interfere with AED analysis & function? |
Yes
No |
| Comments: |
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| Is the proposed AED location accessible at all hours of operation? |
Yes
No |
| Comments: |
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| If utilizing security personnel as members of the response team, are there internal policies addressing whether it is acceptable for them to leave their post to respond to medical emergencies? |
Yes
No |
| Comments: |
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| Is there one or more areas with a higher employee or customer density? |
Yes
No |
| Comments: |
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| Are there any areas where employees may be at a higher risk of cardiac arrest? (ie. Gym area, high stress area, area with electrical or chemical hazards) |
Yes
No |
| Comments: |
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| Is there a “high visibility area” or a place near other emergency equipment (ie. First aid kit, Fire Extinguisher, etc.) that may improve the chances of prompt AED use during a cardiac arrest? |
Yes
No |
| Comments: |
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| Is there a power source near the planned AED placement site? |
Yes
No |
| Comments: |
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| Is there a telephone within close visual proximity of the AED location? |
Yes
No |
| Comments: |
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| Is there a low risk area where the AED can be mounted to be less vulnerable to tampering, theft or damage? |
Yes
No |
| Comments: |
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| How many people are employed at this site? |
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| How many are usually onsite each day or shift? |
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| What are the hours of operation? |
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| If your company does have different shifts, please list (or estimate) each shift and the number of employees working during each one. |
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| Are there areas of your company open to the public? If you answer yes, please comment on the number if public individuals you expect to be in these areas at peak times. |
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| Is there an intercom or overhead paging system? |
Yes
No |
| If yes, can all personnel access the paging system? |
Yes
No |
| How many floors are present in the building? |
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| What is the approximate dimensions or size (square feet or meters) of the area or building? |
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| Are there any perceived barriers to posting adequate signage? |
Yes
No |
| What is the wall made out of (ie. concrete, drywall etc.) in the proposed location for the AED(s)? |
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| Are there any other identified concerns for safety or that might delay a response, and if so, comment? |
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| What is the average number of individuals at your location? |
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| How many of these individuals are 50 or over? |
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| Is the location: |
A residential or 7 day a week commerical site
A non-residential or 5 day business site |
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| * Required |
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