Helpful Documents, Forms & Links

Helpful Documents, Forms & Links


State & County Forms


This packet provides the forms required in New York State. If outside New York State, please research the form(s) required for your locality.

Susquehanna Regional EMS Council PAD Information Packet – most of this packet is background information on setting up an AED program, so don’t let the size of the packet scare you! Save it to your computer. When you open the PDF on your computer, the two forms required by NYS will be “editable” – you can type your answers directly into the form and print it for the required signatures.

The pages below are REQUIRED by the NYS Regional EMS Council to receive your AED from the John Mack Foundation:

  • Notice of Intent to Provide Public Access Defibrillation (DOH-4135) – page 3
  • Public Access Defibrillation Agency Collaborative Agreement – pages 4 & 5 – this establishes a relationship with a Physician (the document refers to this as your Emergency Healthcare Provider) who oversees your program. If your organization has a physician on the board or one active in your organization, you can ask that physician. If not, contact the Emergency Medical Services Coordinator for your county and he/she can assist you in setting up a physician for your organization.
    • Broome County – Raymond Serowik – (607) 778-2184
    • Tioga County – Connie Fedorowicz – (607) 687-8470
  • See pages 6 & 7 of the information packet for a list of the Regional Emergency Medical Services (EMS) Council addresses for each county. Send your paperwork to the appropriate Regional EMS Council.
  • Provide the John Mack Foundation with a copy of your paperwork via scan/email.



John Mack Foundation Forms & Links


Request an AED from the John Mack Foundation

John Mack Foundation Release of Liability and Indemnification Agreement

CPR/AED Training Resources

Donation Form (if you prefer to mail your donation rather than do online)

Like the John Mack Foundation facebook page to keep up with all the latest news and events



Helpful Documents


Key Steps to Implementing an AED Program – coming soon!

Sample Organizational AED Policies and Procedures – coming soon!

Susquehanna Regional EMS Council PAD Case Report

  • Any use of the AED on a person, regardless of reason or outcome, must be reported promptly to your Regional EMS Council.
  • The Case Report above is the form for the Susquehanna Regional EMS Council that covers these counties:
    • Broome
    • Chenango
    • Tioga
  • If you are in a different county, please contact your Regional EMS Council for the appropriate form.



Helpful Links


American Heart Association

Heart & Stroke Foundation of Canada – for our Canadian friends ;)

American Heart Association’s Hands-Only™ CPR