HomeMy WebLinkAboutems-aed-registrationform-website-06072023Alameda County EMS Revised: June 7, 2023 Page 1 of 1
Notice of New Automatic External Defibrillator Program
Alameda County EMS Agency
AED:Initial Renewal AED Relocated Update
Location of AED
Company Name: ______________________________________________________________________________
Company Address: _____________________________________ _________________ _____ ___________
On-Site Contact Information
Name of On-Site Contact:________________________________________________________________________
E-mail of On-Site Contact: ________________________________________________________________________
Phone of On-Site Contact: ________________________________________________________________________
Alternate E-mail: ______________________________________ Alternate Phone: ________________
AED Training/Equipment
Floor and Location Information: ________________________________________________________
Person/Organization Performing Training: ________________________________________________________
Phone of Training Organization: ________________________________________________________
Make, Model, Serial number, and Specific Location of AED Unit(s):
_______________________________________________________________________________________________
Prescribing Physician (Optional)
Prescribing Physician’s Name: ___________________________________________________________________
Prescribing Physician’s Phone: ___________________________________________________________________
I have placed an Automatic External Defibrillator at the following location. I am serving as the prescribing physician
for this public access defibrillation program as described in the California Code of Regulations, Section 100031 through 100041.
Signature: __________________________________________________________ Date: __________
(MM/DD/YYYY)
Please complete a separate form for each AED Location. Please mail or email this completed form to Alameda County EMS Agency, Cynthia Frankel, AED/PAD Program Coordinator, 1000 San Leandro Blvd, Suite 200, San
Leandro, CA 94577, Phone: (510) 618-2031 E-mail: cynthia.frankel@acgov.org
FOR EMS AGENCY USE ONLY
Received By: ____________________________ Date: __________ Date Dispatch Notified: __________
(MM/DD/YYYY) (MM/DD/YYYY)