Policy Details

5141.12 FORM AED Registry

5141.12

FORM - Appendix V

STUDENTS

AED REGISTRY FORM

Required by Public Act 98-62

(Please print or type – use one form per each AED)

Name/Address of Owner of AED: ____________________________________________________________________________

________________________________________________________________________________________________________

Name/Phone Number of Contact Person for AED: _______________________________________________________________

________________________________________________________________________________________________________

AED Manufacturer:_____________________________ Model:____________________ Serial #:__________________________

Name/Address/Phone Number of Prescribing Physician: _________________________________________________________

________________________________________________________________________________________________________

If AED is situated at a fixed location please include full address, building's name, street address, floor/room location. Be as specific as possible: ______________________________________________________________________________________

________________________________________________________________________________________________________

If AED will not be in a fixed location, describe how and where it will be deployed: _______________________________________

________________________________________________________________________________________________________

________________________________________________________________________________________________________

Mail completed form to: State of Connecticut, Department of Public Health
OEMS-AED registry
410 Capitol Avenue MS#12-EMS
P.O. Box 340308
Hartford, CT 06134-0308


Litchfield Board of Education
Form Adopted: February 15, 2006

Download a PDF of this Form

Powered by Finalsite