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AED Registration Form

Missouri law (RSMo 190.092) requires the owners of Automated External Defibrillators (AEDs) to register with local emergency medical services so that emergency communications and medical services personnel may be aware of an AED placement within their jurisdiction. If you or your organization place an AED anywhere in Audrain County, completing our AED registration form fulfills your obligation of notification.

The information you submit will be stored securely in the Computer Aided Dispatch (CAD) system used by Joint Communications.

To register your AED with the local emergency service agencies, please fill out the following form. Move from one box to another by using the tab key or clicking in each box. (Pressing the enter or return key may cause a partially completed form to be submitted.)

* = required field

AED Owner Please enter the name of the organization or individual that owns the AED.
AED Owner's Name: *
AED Prescribing Physician's Contact Information Please enter the name of the physician who prescribed the AED, if any.
Physician's Name:
Physician's Address:
City:
State:
Zip Code:
Telephone:
AED Coordinator/Owner's Contact Information
AED Coordinator's Name: *
AED Coordinator's Address: *
City: *
State: *
Zip Code: *
Telephone: *
E-Mail Address:
AED Equipment Information
Date AED Installed (MM/DD/YY):
AED Manufacturer: *	Access CardioSystems Cardiac Science Hewlett Packard MRL (Medical Research Laboratories) Philips Physio-Control Zoll Other
AED Model Number: *
AED Serial Number: *
AED Location *Please note: Local EMS agencies will be notified of your AED registration based on the address information entered below. Please be sure to put the address where the AED is physically located rather than your corporate headquarters or other address.
Address: *
City: *
State: *
Zip Code: *
Where is the AED located at the address? Be as specific as possible. *
What is your CPR/AED training status?
I/We have already completed CPR/AED training. I/We have scheduled CPR/AED training. I/We need CPR/AED training.
Spam Check
In the box type: nospam

Please verify your information before clicking submit.

Upon submission, you will receive a confirmation copy of the information you submitted, which may be printed for your records. Your entry will be added to the AED Registry database, and your local emergency service agency/agencies will be notified of the location of your AED.

 
This page last updated on: January 17, 2010 at 11:51 am

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