Contact Name *

Email *

Physical address of site

Position

Phone Number

Date

Is there "enhanced" 9-1-1 coverage in the area?

Yes
No

Comments

Is there clear EMS access to the property?

Yes
No

Comments

Are there any "horizontal" barriers to action? (Examples of this would be crowded hallways, catwalks, secured doorways or work areas that may have potentially hazardous materials as in a manufacturing setting)

Yes
No

Comments

Are there any vertical barriers to action? (ie, would an elevator or stairwell have to be used?)

Yes
No

Comments

Are there any areas that present unique access problems (security access coded doors, etc.?)

Yes
No

Comments

Is the proposed AED location accessible at all hours of operation?

Yes
No

Comments

If utilizing security personnel as members of the response team, are there internal policies addressing whether it is acceptable for them to leave their post to respond to medical emergencies?

Yes
No

Comments

Are there any areas where employees may be at a higher risk of cardiac arrest? (ie. Gym area, high stress area, area with electrical or chemical hazards)

Yes
No

Comments

Is there a "high visibility area" or a place near other emergency equipment (ie. First aid kit, Fire Extinguisher, etc.) that may improve the chances of prompt AED use during a cardiac arrest? (ie. Gym area, high stress area, area with electrical or chemical hazards)

Yes
No

Comments

Is there a telephone within close visual proximity of the AED location? Yes No

Yes
No

Comments

Is there a low risk area where the AED can be mounted to be less vulnerable to tampering, theft or damage?

Yes
No

Comments

How many people are employed at this site?

How many people are usually onsite each day or shift?

What are the hours of operation?

If your company does have different shifts, please list (or estimate) each shift and the number of employees working during each one.

Are there areas of your company open to the public? If you answer yes, please comment on the number if public individuals you expect to be in these areas at peak times.

Yes
No

Comments

Is there an intercom or overhead paging system?

Yes
No

If yes, can all personnel access the paging system?

Yes
No

How many floors are present in the building?

Are there any other identified concerns for safety or that might delay a response, and if so, comment?

The rest of the questions are based upon the formula to determine if a site is a high risk location:

A high risk location is an area which has a likelihood of having an event more frequently than every five years. The formula is based on the following information.**

It is important to remember that there is no formula that can accurately determine whether or not you will have an incident in your location, however, from a statistical perspective, these questions can help roughly determine the chances of a cardiac arrest.

What is the average number of individuals at your location?

How many of these individuals are 50 or over?

This location is:

A residential or 7 day a week commercial site
A non-residential or 5 day business site

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