Title Page

  • Client / Site Location

  • Conducted on

  • Conducted by

  • Location

1. Routine Maintenance Items

  • 1.1 Is there evidence that routine inspection are conducted? e.g. every 12 months NOTE: Ensure maintenance log has been filled out

  • Equipment Make
  • Type of Equipment

  • List asset number

  • Date of last inspection

  • 1.2 Is the Active Status Indicator (ASI) is flashing green?

  • 1.3 Are the pads in good condition and within the expiry date?

  • 1.4 Is the battery pack within expiry date?

2. Perform Self-test

  • 2.1 Did the unit pass the self-test? NOTE: Refer to the specific operations manual for the self-test procedure

3. Competency

  • 3.1 Are workers familiar with the use and maintenance of the defibrillator?

4. Signage

  • 4.1 Are relevant signs displayed near equipment?

5. Information

  • 5.1 Is the operator manual available with the device?

  • Add photos of unit and accessories

6. Additional Hazards

    List any additional hazard identified
  • Hazard details

  • Take photo of issue


  • Perform a self-test to ensure the defibrillator is functioning correctly. Refer to the operators manual.

  • Signature below is confirmation that the defibrillator and related equipment, including pads and battery, were checked/ tested and were functioning correctly at the time of inspection. The defibrillator was taken out of maintenance mode and left in a ready state. The green Active Status Indicator (ASI) light was operating when the equipment was put back into service.

  • Signature of auditor

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