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Name |
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Title |
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Company |
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Address 1 |
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Address 2 |
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City |
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State/Province |
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Zip/Postal |
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Telephone |
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Fax |
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E-mail |
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Facility/Property
Name |
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Contact Name |
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Contact
Title |
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Address 1 |
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Address 2 |
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City |
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State/Province |
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Zip/Postal |
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Facility
Telephone |
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Facility Fax |
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Contact
Telephone |
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Contact
E-mail |
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Is there
a
documented
emergency
response
plan
that
incorporates
the use
of AEDs
in
accordance
with
state
and
local
AED
requirements?
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Is there
a
physician
involved
in the
oversight
of the
AED
program?
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Has the
local
EMS
system
been
notified
of your
facility's
AED
program?
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Has the
local
hospital
emergency
department
been
notified
of your
facility's
AED
program?
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Have the
proper
number
and
placement
of
FDA-approved,
biphasic,
AEDs
been
determined
and
installed
so that
from any
point
within
the
public
and
meeting
space as
well as
any
contiguous
outdoor
pool
areas,
tennis
courts
and
restaurant
areas,
at least
one AED
will be
within a
travel
distance
that
provides
for
retrieval
and
arriving
at
Sudden
Cardiac
Arrest
victim's
side
within
three
(3)
minutes?
Assuming
an
average
walking
speed of
4.75
feet per
second,
and an
average
elevator
wait
time of
60
seconds
(where
applicable),
sample
placement
guidelines
are as
follows:
-
Travel
distance
of
400
ft
or
less
if
on
same
floor,
or
accessible
by
stairs/escalator/ramp
-
Travel
distance
of
250
ft
or
less
if
housed
in
an
elevator
cab,
in
which
case,
every
publicly
accessible
elevator
should
be
equipped
with
an
AED.
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Is there
an AED
with a
travel
distance
of 75
feet or
less
from
the:
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Security
Office
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Front
Desk
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Health
Club
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Total number
of publicly
accessible
AEDs
currently
in-service |
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Total number
of AEDs that
are NOT
publicly
accessible
currently
in-service |
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AED
Manufacturer: |
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If
"Other",
please
specify
manufacturer
and
model: |
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Is each
publicly
accessible
AED
housed
in a
recessed
or
surface
mounted
wall
cabinet
with
audiovisual
alarm
and/or
automated
notification
of
emergency
personnel?
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Do all
security/safety
staff
plus at
least
one
additional
full-time
employee
for each
AED in
service
hold a
current
course
completion
card/certificate
for one
of the
following
programs,
which
include
AED
training?
-
American
Heart
Association
(Heartsaver
AED
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AED
and
Adult
CPR;
Heartsaver
AED
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AED,
Adult
and
Pediatric
CPR;
Heartsaver
First
Aid
with
CPR
and
AED;
Heartsaver
Instructor
-
CPR
and
AED)
-
American
Red
Cross
(Workplace
Training:
Standard
First
Aid;
Adult
CPR)
-
National
Safety
Council
(CPR
and
AED;
Standard
First
Aid,
CPR,
and
AED)
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Total number
of trained
responders
currently
working on
behalf of
your
facility: |
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AED
training
provided
by:
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If
"Other",
please
specify
the
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Training
provider
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Is there
a plan
and
process
by which
the
manufacturer's
recommended
service
schedules
(including
inspection,
testing,
maintenance,
and
replacement
of
consumables)
are
executed
and
recorded
for each
AED and
wall
cabinet
including
the date
of each
service
activity
and the
signature/initials
of the
agent
performing
the
service?
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Is
information
regarding
AEDs,
including
location,
provided
at
check-in
and/or
in the
guest
rooms?
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"I
attest
that,
to
the
best
of
my
knowledge,
the
responses
above
are
accurate,
and
acknowledge
that
these
responses
will
be
relied
upon
by
CR
Certification
Corporation
in
assessing
the
facility
listed
below.
CR
Certification
Corporation
will
provide
to
the
facility
a
CardioReady®
certification
status
review
and
recommendation
of
any
steps
that
would
be
required
to
bring
the
facility
in
line
with
the
requirements
for
CardioReady®
certification.
Should
you
wish
CR
Certification
Corporation
to
proceed
with
this
"no
charge"
assessment,
please
choose
"Accept"
below.
Acceptance
in
no
way
represents
a
facilities
desire
or
obligation
to
proceed
further
with
the
CardioReady®
certification
process."
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I
"Accept"
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