Defibrillator Inspection Survey Form
Use this form to record AED/defibrillator inspection results, readiness status, and any maintenance follow-up needed.
Device Identification
Site Name
*
Exact Device Location
*
Asset Tag / Device ID
*
Manufacturer
*
Model
*
Serial Number
Inspection Check Results
Inspection Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Inspector Name or Role
*
Overall Readiness Status
*
Ready
Needs Attention
Not Available
Unknown
Power Indicator / Status Light
*
Pass
Needs Attention
Not Available
Unknown
Battery Condition
*
Pass
Needs Attention
Not Available
Unknown
Pad / Electrode Expiration Status
*
Pass
Needs Attention
Not Available
Unknown
Pad Packaging Condition
*
Pass
Needs Attention
Not Available
Unknown
Cabinet / Accessibility
*
Pass
Needs Attention
Not Available
Unknown
Alarm or Security Seal Status
*
Pass
Needs Attention
Not Available
Unknown
Maintenance Details and Notes
Missing or replaced items
Electrode pads
Battery pack
Charging cable
Wall mount
User manual
Keys/locks
Other
Corrective action needed
Date and time of last maintenance or service
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Follow-up required
*
Yes
No
Urgency level
*
Please Select
Low
Moderate
High
Critical
Additional notes and observations
Submit Inspection
Should be Empty: