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Application for assessment and registration of an automated external defibrillator
Use this form to apply to Automated External Defibrillator (AED) Deployment Registry (AEDDR) for assessment and registration of an AED under AEDDR 1410
You must complete one form and pay the applicable fee for each AED
Who should AEDDR contact if there is a query about this form?
Firm/organisation
ABN
First Name
Last Name
Position description
Telephone number (during business hours)
Email address
Postal address
Suburb/City
State/Territory
Post Code
1. Details of the Applicant/Registrant
Firm/organisation
ABN
First Name
Last Name
Position description
Telephone number (during business hours)
Email address
Postal address
Suburb/City
State/Territory
Post Code
2. Details of the workplace
Number of workers at workplace
Workplace has power
No
Yes
Workplace has communications
No
Yes
AED is located within 2 minutes of potential victim
No
Yes
3. Details for ambulance
If consent to public access is granted these details will be available as part of the public register.
Name of site
Name of emergency contact
Telephone number (during business hours)
Telephone number (after business hours)
Street address
Nearest cross street
Special instructions
Location of AED
Latitude
Longitude
4. Consent for public access
It is agreed that the information contained in items 3 and 5 will be available to the public both in written and mapping form both via the internet and smart phone applications at www.nearestdefib.com. It is further agreed that a member of the public is granted access to the AED in the event of a cardiac emergency.
Consent to public access is granted
5. Normal hours of public access (excluding public holidays)
Monday (open from) (am/pm)
Monday (close at) (am/pm)
Tuesday (open from) (am/pm)
Tuesday (close at) (am/pm)
Wednesday (open from) (am/pm)
Wednesday (close at) (am/pm)
Thursday (open from) (am/pm)
Thursday (close at) (am/pm)
Friday (open from) (am/pm)
Friday (close at) (am/pm)
Saturday (open from) (am/pm)
Saturday (close at) (am/pm)
Sunday (open from) (am/pm)
Sunday (close at) (am/pm)
6. Details of AED
Manufacturer
Model
AED Reference Number
AED date of MANUFACTURE
+
AED Serial Number
Battery ID Number
Battery date of Manufacture
+
Electrode Serial Number
Electrode Expiry Date
+
Spare electrode serial number
Spare electrode expiry date
+
7. AED accessibility
AED is sign posted
No
Yes
AED is unlocked
No
Yes
AED is readily visible
No
Yes
8. AED reliability
AED is electronically monitored
No
Yes
AED is inspected/logged daily
No
Yes
AED self-testing includes a full energy charge cycle on a monthly basis
No
Yes
9. AED ease of use
AED is fully automatic (no button to administer therapy)
No
Yes
AED has interchangeable pads
No
Yes
AED has both visible and audible rescue prompts
No
Yes
10. AED training
10 people are trained annually in basic life support
No
Yes
Training records are up to date
No
Yes
Signature
This form must be signed by a manager with appropriate delegation or a professional consultant with professional indemnity insurance cover of at least $5 million dollars.
I certify that the information in this form is true and correct
Name
Capacity of person signing (Manager with appropriate delegation/Professional consultant)
Signature
clear
Date
+
For more information, including information about fees payable
Email: applications@aeddr.com
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