Defibrillator Location Report Form
Use this form to report and document the exact location and details of a defibrillator/AED.
Reporter Full Name
*
First Name
Last Name
Reporter Email Address
*
example@example.com
Reporter Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Facility or Site Name
*
Exact Location (address, building, floor, room, or nearby landmark)
*
Device Type
*
Please Select
AED (Automated External Defibrillator)
Manual Defibrillator
Other
Accessibility
*
Publicly accessible
Staff access only
Restricted access
Working Status
*
Operational
Needs maintenance
Out of service
Date of Last Inspection or Check
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Special Instructions or Issues
Submit Report
Should be Empty: