Attachment 27 DSCC 2278-AED Class Registration Form.pdf

PDF (DLA)DSCC FORM 2278, SEP 2006

AUTOMATED EXTERNAL DEFIBRILLATION (AED) CLASS REGISTRATION FORM

Basic Life Support Heartsaver AED Course

MUST BE FILLED OUT TO RECEIVE CARD

PREVIOUS EDITION IS OBSOLETE

WILL YOU SERVE?

NAME (Last, First, MI)DATE PHONE NUMBER

ACTIVITY CODE (Ex: CA, CC, H6) ORGANIZATION (Ex: DSCC, DFAS, DHRC, DES) OFFICE SYMBOL (Ex: CE, NACA, BKJWC)

BUILDING # (Ex: 21, 20, 11) SPECIFIC LOCATION (Ex: 020C3N004, Sec. 3, cube 013)

If you are interested in an AED Quick Reference Guide with CPR Face Shield to carry in your glove compartment, wallet, or purse, stop by the Environmental, Safety, and Occupational Health Office.

Are you willing to serve for the next 2 years to be a member of the "First Response Team"? Please check one:

"FIRST RESPONSE TEAM" members agree to volunteer to perform CPR or use an AED device on an individual in your area, if an emergency occurs, until the Emergency Squad arrives. They also agree to post a flag in their workstation and to post magnetic nameplate when boards are available, to signify that they are trained in CPR/ AED. If you agree to be a member, stop by the Environmental, Safety, and Occupational Health Office to sign the "Volunteer Statement for First Response Team" and pick up a flag.

YES NO

PDF (DLA)

DSCC FORM 2278, SEP 2006

AUTOMATED EXTERNAL DEFIBRILLATION (AED) CLASS REGISTRATION FORM

Basic Life Support Heartsaver AED Course

MUST BE FILLED OUT TO RECEIVE CARD

PREVIOUS EDITION IS OBSOLETE

WILL YOU SERVE?

If you are interested in an AED Quick Reference Guide with CPR Face Shield to carry in your glove compartment, wallet, or purse, stop by the Environmental, Safety, and Occupational Health Office.

Are you willing to serve for the next 2 years to be a member of the "First Response Team"? Please check one:

"FIRST RESPONSE TEAM" members agree to volunteer to perform CPR or use an AED device on an individual in your area, if an emergency occurs, until the Emergency Squad arrives. They also agree to post a flag in their workstation and to post magnetic nameplate when boards are available, to signify that they are trained in CPR/AED. If you agree to be a member, stop by the Environmental, Safety, and Occupational Health Office to sign the "Volunteer Statement for First Response Team" and pick up a flag.

Cynthia Pillitteri, 614-692-3964 DES-CE (Columbus)

Safety One Book Chapter, Section 4.6.2.4.

NO

Automated External Defibrillation (AED) Class Registration Form DSCC Form 2278, Sep 2006