Helpful Documents, Forms & Links

Helpful Documents, Forms & Links

 

State & County Forms

 

Here’s links to information on setting up an AED program and the paperwork required in New York State.

If outside New York State, please research the form(s) required for your locality.

When establishing an AED program in NYS, it’s referred to as a PAD (Public Access Defibrillation) program.

A PAD program is a plan to place an Automatic External Defibrillator (AED) in a workplace, school, house of worship or other public gathering place and train people to use it. The goal is to reduce the number of deaths associated with sudden cardiac arrest.

 

NYS Department of Health – PAD Policy Statement

Informational packet on setting up a PAD program in NYS.

 

NYS Department of Health – Notice of Intent to Provide Public Access Defibrillation (PAD)

This form is REQUIRED by your county’s Regional EMS Council.

Save this file to your computer. When you open the PDF on your computer, the form will be “editable” – you can type your answers directly into the form, save it and print it for the required signatures.

 

Public Access Defibrillation Agency Collaborative Agreement

This establishes a relationship with a Physician (the document refers to this as your Emergency Healthcare Provider) who oversees your program.

This form is REQUIRED by your county’s Regional EMS Council.

Save this file to your computer too. When you open the Word document on your computer, you’ll be able to type your answers directly into the form, save it and print it for the required signatures.

 

AED Paperwork Instructions

When we email you that your AED request has been approved, we will include instructions that guide you field-by-field through the required AED paperwork. If you have questions at any point, please contact us so we can help.

 

Public Access Defibrillation (PAD) Program Start-Up Checklist

Helpful checklist provided by the Susquehanna Regional EMS Council on the steps required to complete the AED process.

 

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