Form DHHS/DHSR/EMS4930 "Aed Placement Notification for Ems" - North Carolina

What Is Form DHHS/DHSR/EMS4930?

This is a legal form that was released by the North Carolina Department of Health and Human Services - a government authority operating within North Carolina. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on December 1, 2020;
  • The latest edition provided by the North Carolina Department of Health and Human Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form DHHS/DHSR/EMS4930 by clicking the link below or browse more documents and templates provided by the North Carolina Department of Health and Human Services.

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Download Form DHHS/DHSR/EMS4930 "Aed Placement Notification for Ems" - North Carolina

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AED Placement Notification for EMS
TO: NC OFFICE OF EMS
(Fax# 252-208-2027 or email jackie.ward@dhhs.nc.gov)
In accordance with North Carolina General Statute § 90-21.15 (g), we are required by state law and/or contract to
notify local EMS of the purchase or deployment of an AED (Automated External Defibrillator) within our coverage
area. Below is the notification document for the acquisition and deployment which includes the purchaser
information, location, and type of AED.
Purchaser Information
AED Distributor:
Purchase Price:
AED Purchaser:
Acquired Date:
Purchaser Address:
City:
State:
Zip:
Telephone:
Fax Number:
E - Mail Address:
Contact:
Location of AED:
Model Number:
Serial Number:
Manufacturer Information
AED Manufacturer:
Address:
City:
State:
Zip:
Telephone:
Fax Number:
E - Mail Address:
Please accept this document as confirmation of placement of AED in above-referenced locations.
– FOR NC OFFICE OF EMERGENCY MEDICAL SERVICES USE ONLY –
Received by:____________________________
Date received:__________________
Entered in Database: Y / N
Comments:________________________________________________________________________________________
_________________________________________________________________________________________________
DHHS/DHSR/EMS 4930
Rev.12/20
AED Placement Notification for EMS
TO: NC OFFICE OF EMS
(Fax# 252-208-2027 or email jackie.ward@dhhs.nc.gov)
In accordance with North Carolina General Statute § 90-21.15 (g), we are required by state law and/or contract to
notify local EMS of the purchase or deployment of an AED (Automated External Defibrillator) within our coverage
area. Below is the notification document for the acquisition and deployment which includes the purchaser
information, location, and type of AED.
Purchaser Information
AED Distributor:
Purchase Price:
AED Purchaser:
Acquired Date:
Purchaser Address:
City:
State:
Zip:
Telephone:
Fax Number:
E - Mail Address:
Contact:
Location of AED:
Model Number:
Serial Number:
Manufacturer Information
AED Manufacturer:
Address:
City:
State:
Zip:
Telephone:
Fax Number:
E - Mail Address:
Please accept this document as confirmation of placement of AED in above-referenced locations.
– FOR NC OFFICE OF EMERGENCY MEDICAL SERVICES USE ONLY –
Received by:____________________________
Date received:__________________
Entered in Database: Y / N
Comments:________________________________________________________________________________________
_________________________________________________________________________________________________
DHHS/DHSR/EMS 4930
Rev.12/20