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San Mateo County Public Access Defibrillator (PAD) Program
Notification to Emergency Medical Services Agency
Organization Contact Information
Organization/Company: / Main Phone:
Address: / City: / Zip:
AED Program Information
Program Medical Director: / Phone: / Email:
Site Defibrillation Coordinator: / Phone: / Email:
Site Address: / City: / Zip: / No. of AEDs On-site:
Please complete the table below for each AED being registered. Be sure to include the following information for each entry:
·  Placement/location for each AED (be specific)
·  Make and model
·  Is the AED listed New (N), Existing (E), or a Deletion (D)?
·  Is the AED Public Access? If ‘Yes’ list the days and times the unit is accessible (e.g. M-F, 8:00 AM-5:00PM)
·  Indicate whether AED location data may be shared with Pulse Point (Link to Pulse Point website: http://www.pulsepoint.org/)
Optional – To help us improve location accuracy, please provide coordinates for each of the listed AEDs. Coordinates can found using most online or mobile mapping applications. To find the coordinates though Google Maps, go to maps.google.com, and type in the address of the listed AED. Zoom in on the area where the AED is located, and position the cursor arrow on the spot where the AED is located. Right click and select ‘What’s here?’ from the menu. A box with description and coordinates should pop-up. Copy and paste the coordinates to appropriate field in this form.
Describe the placement of the AED(s) (e.g. Building 2 – 1st floor main lobby, behind front desk) / Make/Model of AED / New, Existing or Deletion (N/E/D) / Public Access
(Y/N) / If ‘Yes’ to Public Access, when is the AED(s) accessible (e.g. M-F, 8:00 AM-5:00PM) / AED Coordinates
PLEASE EMAIL COMPLETED FORMS TO:
Forms may also be submitted via mail or fax: /
San Mateo County EMS Agency
801 Gateway Blvd, Ste. 200
South San Francisco, CA 94080
Fax: 650-573-2029
Please direct questions or comments to: / Patrice Christensen, RN PHN

(650) 573-3728
Garrett Fahey

(650) 573-2009