Original Notification Update
Entity Providing PAD
( )
Telephone Number
Name of Organization Agency Code
Name of Primary Contact Person
E-Mail Address
Address
( )
Fax Number
City
State Zip
Type of Entity (please check the appropriate boxes)
Business
Ambulance
Fire Department/District
Private School
Construction Company
Police Department
College/University
Health Club/Gym Local Municipal Government
Physician’s Office
Recreational Facility
County Government
Dental Office or Clinic
Industrial Setting
State Government
Adult Care Facility
Retail Setting
Public Utilities
Mental Health Office or Clinic
Transportation Hub
Public School K – 12
Other Medical Facility (specify)
Restaurant
Other (specify)
PAD Training Program CPR AED training program must meet or exceed current ECC Standards.
Automated External Defibrillator
Manufacturer of
Yes No
Number of Trained
Number
AED Unit
PAD Providers
of AEDs
Emergency Health Care Provider
Name of Emergency Health Care Provider (Hospital or Physician) Physician NYS License Number
Address
City State Zip
Name of Ambulance Service and 911 Dispatch Center
Name of Ambulance Service and Contact Person
Name of 911 Dispatch Center and Contact Person County
Authorization Names and Signatures
CEO or Designee (Please print) Signature Date
Physician or Hospital Representative (Please print) Signature Date
DOH-4135 8/16 Send completed form and Collaborative Agreement to the REMSCO in your area.
Notice of Intent to Provide
Public Access Defibrillation
Is the AED
Pediatric Capable?
( )
Fax Number
( )
Telephone Number
NEW YORK STATE DEPARTMENT OF HEALTH
Bureau of Emergency Medical Services and Trauma Services
( )
Telephone Number
