DELAWARE HEALTH AND SOCIAL SERVICES
Division of Public Health
Office of Emergency Medical Services

FIRST STATE FIRST SHOCK POTENTIAL UNIT FORM

Date:_______________________________________________________________________________________________

Organization:_______________________________________________________________________________________

Location:___________________________________________________________________________________________

Contact Person:_____________________________________________________________________________________

Telephone Number (include Area Code):_______________________________________________________________

Instructions:  This form is used to assist the Office of Emergency Medical Services in determining 
appropriate locations for public access defibrillators.  Please answer each of the following questions.

Send the completed form to:
Assistant AED coordinator
Office of Emergency Medical Services
Blue Hen Corporate Center
655 Bay Road, Suite 4H
Dover, DE  19901

1.	Number of days per year the facility is opened:  ___________________

2.	Number of visitors(1):   ____________  per	day    week    month    year (Circle one.)

3.	Number of residents(2):	_____Not Applicable		___________

4.	Percent of visitors over the age of 40: ____________

5.	Number of employees(3):  ____________

6.	Percent of employees over the age of 40: ____________

7.	Average number of hours a visitor may spend on the property:  __________per day

8.	Hours per work day: __________ 

9.	Number of cardiac arrests in the last four years:  __________	_________Unknown

10.	Name of local police agency: __________________________________________________________________

11.	Name of local Fire/EMS Agency: ________________________________________________________________

Footnotes:

(1)  Visitors—Individuals, including customers, who are not employees of the organization.
(2)  Residents—Individuals who reside in hotels, room and board facilities, nursing home, assisted 
     living facilities, apartments, and other facilities providing sleeping rooms.
(3)  Employees—Individuals, including volunteers, who work for an organization.

Doc. #35-05-20/07/03/29