Automatic External Defibrillator (AED) Monthly Checklist
MEDTRONICS / PHYSIO CONTROL
TO BE MAINTAINED FOR REVIEWAND AVAILABLE UPON REQUEST FOR EACH AED
(One form for each AED)
Campus ______
Administrator ______
School Nurse/CPR-Trained Designee ______
List names of at least 2 trained staff members (including school nurse)
______
Instruction / Date201 _- 201_ / August
____ / Sept
___ / Oct
___ / Nov
___ / Dec
___ / Jan
___ / Feb
___ / Mar
___ / April
___ / May
___ / June
___ / July
___
Initials
1. If the OK symbol is visible your AED requires no action at this time. Continue to monitor routinely per the Operating Instructions. / P to indicate completion
2. If the OK symbol is not visible, and
the CHARGE-PAK symbol () is visible, it is now time to replace the CHARGE-PAK. If your current CHARGE-PAK has been installed for less than 2 years, your device may be affected by the electrical problem described above. Contact Physio-Control Technical Support and they will work with you to determine next steps. * / P to indicate completion
3. If the OK symbol is not visible, and either the ATTENTION () or WRENCH () symbols are present, your device requires immediate attention to ensure its readiness. Contact Physio-Control Technical Support immediately to determine next steps. * / P to indicate completion
4. Check defibrillator for damage (i.e. cracks, foreign substances) / P to indicate completion
5. Check “Use by” date on all pads / P to indicate completion
6. Was AED activated for use with CPR this month? (911 report of details to Health and Medical Services required). / yes/no
*Contact Information Physio-Control: www.physio-control-notices.com/CHARGE-PAK or call Technical Support at 1-800-442-1142, 6:00 a.m. to 4:00 p.m. (Pacific), Monday-Friday.
Signatures: ______
School Administrator Date School Nurse Date
Revised April 2013