e. Disposition Procedures. Affix the DA Label 175 as close as possible to the
control panel on the defibrillator. When the label cannot be affixed to the equipment
because the item is too small or because its intended use prohibits the label, one of the
following methods will suffice.
(1) Maintain a log book in the immediate vicinity which contains the
applicable label for the medical item.
Affix the label to a tag which, in turn, is fastened to the medical
(3) Fasten the label to the outside lid of the case. Previous labels must be
voided, removed and destroyed, or you can place the new label over the old label.
DA FORM 5624-R, DC DEFIBRILLATOR INSPECTION RECORD
The front and back of a blank DA Form 5624-R are shown in figures 2-3 and 2-4.
a. Purpose. The DA Form 5624-R provides a record for the certification of
energy output and performance inspection for defibrillators.
b. Use. Use the DA Form 5624-R for documenting energy output and
defibrillator performance inspections.
c. Required Equipment. In addition to the blank form and a pen, you will need
a medical safety analyzer to complete this task.
d. Preparation. When performing tests and inspections, follow instructions per
the equipment's TM or manufacturer's literature.