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NOTE:

For official copies of board policies and procedures please contact the superintendent's office at (253) 583-5190 or email supt@cloverpark.k2.wa.us

Form 3412-F1

CLOVER PARK SCHOOL DISTRICT
AED INSPECTION FORM

USE THIS FORM FOR MONTHLY INSPECTIONS

Inspected By:
Location of Inspection (Building):
Date of Inspection:

Use the following maintenance checklist when you inspect your unit.

Check the following Pass Fail Comments
Is the Quick Start Set Up Guide and Owner’s Manual inside the AED Box?
Is the green check showing that the unit is ready to use?
Is the unit clean, undamaged and free of excessive wear?
Are there any cracks or loose parts in the housing?
Verify electrodes are connected to the unit and sealed in their package. Replace if expired.
Turn the unit on and off and verify the green check indicates ready for use.
Batteries within expiration date. Replace if expired
Alarm on AED Box operates correctly. Replace batteries if expired.
3412-F4 – Facility emergency plan is updated annually and is stored with the AED prior to use

If any item above is marked “FAIL” and the deficiency is not correctable, this form must be forwarded to the Clover Park School District Risk Management Office or Maintenance Division for immediate correction.

Cleaning the Unit

  • After each use, clean and disinfect the unit with a soft, damp cloth using 90% isopropyl alcohol, or soap and water, or chlorine bleach and water mixture (30 ml/liter water).
  • Do not immerse any part of the unit in water.
  • Do not use ketones (MEK, acetone, etc.) to clean the unit.
  • Avoid using abrasives (e.g., paper towel) on the display window or around data ports.
  • Do not sterilize the device.

SEND COMPLETED FORMS TO DISTRICT RISK MANAGEMENT OFFICE

ENVIRONMENTAL HEALTH & SAFETY USE ONLY
Work Order Number
Schedule Date
Completion Date
Action Required