Fillable AED Placement Notification for EMS (North Carolina)

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AED Placement Notification for EMS (North Carolina)

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AED Placement Notification for EMS
TO: NC OFFICE OF EMS (Fax# 252-208-2027 or email jackie.ward@dhhs.nc.gov)
In accordance with North Carolina General Statute § 90-21.15 (g), we are required by state law and/or contract to
notify local EMS of the purchase or deployment of an AED (Automated External Defibrillator) within our coverage
area. Below is the notification document for the acquisition and deployment which includes the purchaser
information, location, and type of AED.
Purchaser Information
AED Distributor:
Purchase Price:
AED Purchaser:
Acquired Date:
Purchaser Address:
City:
State:
Zip:
Telephone:
Fax Number:
E-Mail Address:
Contact:
Location of AED:
Model Number:
Serial Number:
Manufacturer Information
AED Manufacturer:
Address:
City:
State:
Zip:
Telephone:
Fax Number:
E-Mail Address:
Please accept this document as confirmation of placement of AED in above-referenced locations.
– FOR NC OFFICE OF EMERGENCY MEDICAL SERVICES USE ONLY –
Received by:____________________________ Date received:__________________ Entered in Database: Y / N
Comments:________________________________________________________________________________________
_________________________________________________________________________________________________
DHHS/DHSR/EMS 4930 Rev.12/20
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AED Placement Notification for EMS (North Carolina)

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Completed 20 April 2022

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