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AED Data Collection Form

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Personal Information
Name
Email Address
Location of AED
Business / Organization Name*
Business / Organization Phone Number*
Business / Organization Address*
Location of the AED within your Business / Organization*
AED Information
AED Model
1. Physio-control
2. Cardiac Science
3. Philips
4. Other
Purchase Date
Purchase Date
Pads Expiration Date
Pads Expiration Date
Other:*
Battery Expiration Date
Battery Expiration Date
Serial Number
This can be found below the bar code, in a white box left of the bar code, above the bar code, or on the back of the AED towards the bottom.
Purchase Price
AED Distributor and Contact Information
AED / CPR Training
Total number of individuals at your business / organization who are trained in CPR.*
Would you like to host a CPR / AED class?*
1. Yes
2. No
3. I would like more information.