Fillable Automated External Defibrillator Annual Registration (Boone County, Missouri)

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Automated External Defibrillator Annual Registration (Boone County, Missouri)

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C:\Users\anwaner\Downloads\AED Registration Form2 12-2006 (1).doc
Automated External Defibrillator
Annual Registration
The Automated External Defibrillator (AED) Ordinance of Boone County, Missouri, requires that all
persons owning an AED register the device annually with the Columbia/Boone County Health Director.
Please complete the following information and mail to:
Health Director
Columbia/Boone County Department of Public Health and Human Services
P.O. Box 6015
Columbia, MO 65205
Physical Location of AED (if more than one is owned, list location of each device):
AED Owner:
Name
Address:
City, State, Zip
Phone:
E-mail:
Brand/Model:
Medical Protocol:
Physician Name:
Address:
City, State, Zip
Phone:
Please answer the following:
Yes No
Is a copy of the medical protocol maintained on file by the owner? _____ _____
Are potential users trained in AED use and CPR certified? _____ _____
Is a list of persons trained to use the AED maintained on file by the owner? _____ _____
Are records of use and quality assurance evaluations maintained on file by the owner? _____ _____
Has the AED been tested and maintained per the manufacturer’s operating guidelines? _____ _____
Date of last testing and / or service of the AED: _________________________________
For Annual Renewals Only:
How many times has the AED been used in the last 12 months? _______
Did the Physician / Medical Director review each use? ____Yes ____No
I certify that the above information is correct
Owner: __________________________ Physician: __________________________
Date: __________________________ Date: __________________________
For additional information or assistance, contact the Health Department at 573-874-7347
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Automated External Defibrillator Annual Registration (Boone County, Missouri)

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Completed 20 August 2020

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