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One Team United In Service

HEART Safe

Persons rendering emergency assistance through the use of automated external defibrillators – limited immunity.

C.R.S. 13-21-108.1 (2016)

Persons rendering emergency assistance exempt from civil liability.

C.R.S. 13-21-108 (2016)

AED Application Form

Organization Name*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Tax Exempt Status*
501(c)3 Status*
- Yes
- No
Government Agency?*
- Yes
- No
Organization Mission Statement
Contact Person*
First Last
Title*
Phone*
Email*
Trained in CPR?*
- Yes
- No
Person responsible for AED on site*
First Last
Title*
Phone*
Email*
Trained in CPR?*
- Yes
- No
Describe in detail the need, intended deployment strategy of AEDs and total number of AEDs requested. Also include number of existing AEDs and their locations and how any additional AEDs will benefit your organization*
For fixed AED location deployments, are you also requesting an AED wall cabinet?
- Select All
- Yes
- No
How many people do you estimate are at your site on a daily basis?*
How many people do you estimate are at your site during a special event?*
Please detail the organization’s plan for ensuring the expected users of the AED receive and maintain training in CPR.*
Please detail the organization’s plan for ensuring the AED is maintained according to the manufacturer’s guidelines and written records are maintained.*
Please detail the organization’s plan for ensuring the AED is maintained according to Colorado Revised Statues. https://www.tvems.com/en/heart-safe
CPR Training
The Heart Safe Community Initiative is trying to ensure as many people are trained in CPR as possible. Are you willing and able to host a CPR Training* at your site?*
- Yes
- No
*Please note: The CPR training is for people who want to learn CPR, yet do not need CPR certification.
If you are willing and able to host a CPR training, please describe the room where the training will occur and if it has tables, chairs, a presenter’s screen and/ or LCD projector.*
If your site is appropriate to host a CPR training, how many people do you think you could recruit to attend the training?*
Comments
This field is for validation purposes and should be left unchanged.

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