Da Form 5624 R PDF Details

What Is the DA Form 5624 R?

The DA Form 5624 R is the U.S. Army's official defibrillator inspection record, designed for use in military hospitals and medical treatment facilities. It provides a standardized framework for documenting visual inspections and performance tests on defibrillator units, helping authorized medical staff confirm that each device operates within required safety specifications before deployment in patient care settings.

Who Needs This Form?

Military healthcare professionals, biomedical equipment technicians, and inspection officers complete the defibrillator inspection record during each scheduled inspection cycle. The form is required whenever a defibrillator undergoes routine preventive maintenance checks or is first brought into active service. Medical unit commanders and equipment custodians retain completed copies as part of the facility's ongoing maintenance records and equipment accountability files.

Key Components Documented

Inspectors use the form to record the manufacturer's name, model designation, and serial number for precise unit identification. The inspection record tracks both the visual condition of components (including attachment plugs, line cords, paddles, cables, and connectors) and critical performance metrics such as output energy levels and charge times. Internal discharge function results, synchronized operation verification, and any other feature evaluations are also captured during each inspection cycle.

Certification Outcomes

Based on test results, inspectors grant either full certification or provisional certification with required corrective work noted. Full certification with an affixed label confirms the unit meets or exceeds manufacturer specifications and is cleared for active duty. Provisional certification documents any deficiencies found and specifies the corrective actions needed before the defibrillator can be returned to full active service. All certification decisions must be supported by the test data recorded in the form.

Inspection Scheduling and Record Retention

The form captures the inspection date and the next inspection due date, both entered in YYYYMMDD format, ensuring consistent maintenance cycles across all units in the facility. These records support regulatory compliance, assist during audits, and help medical commanders quickly identify equipment that requires attention before it is used in an emergency. Completed forms should be filed in the unit's equipment maintenance folder and retained according to Army records management requirements.

Related Army Forms

Medical maintenance officers often use the defibrillator inspection record alongside other Army documentation. If you work with military medical equipment records, you may also need the DA Form 5019 R for preventive maintenance checks or the Army Certificate DA Form 87 for personnel certifications related to authorized duties.

QuestionAnswer
Form NameDa Form 5624 R
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesda form 5624, defibrillator inspection record
Form CategoryMilitary Medical / Equipment Maintenance
Issuing AuthorityU.S. Army

How to Edit Da Form 5624 R Online for Free

How to Complete This Inspection Record Online

You may prepare this defibrillator inspection record instantly with the help of our PDFinity® editor. We at FormsPal are aimed at providing you the best possible experience with our tool by constantly adding new capabilities and upgrades. Our editor is now a lot more helpful as the result of the newest updates. At this point, filling out PDF files is simpler and faster than ever. Here is what you need to do to get going:

Step 1: Hit the "Get Form" button in the top section of this page to open our tool.

Step 2: The editor offers the opportunity to customize almost all PDF forms in a range of ways. Improve it by adding any text, adjust what's originally in the PDF, and place in a signature - all when it's needed!

Completing the Inspection Fields

When it comes to blank fields of this particular PDF, here is what you need to do:

1. Begin filling out the inspection record with a selection of major fields. Note all of the necessary information and be sure there is nothing left out!

Step number 1 in submitting Da Form 5624 R

2. Once the previous segment is done, you need to include the essential details in CHARGE TIME AT, MAXIMUM ENERGY, PREVIOUS VALUE, SETTING, SEC, SEC, INTERNAL DISCHARGE FUNCTION, ENERGY DELIVERED AFTER MINUTE AT, SETTING, OUTPUT OF TENTH REPEATED DISCHARGE, WSEC, WSEC, SYNCHRONIZED OPERATION, OTHER FEATURES Specify, and FULL CERTIFICATION WITH LABEL so that you can move forward to the 3rd step.

How you can complete Da Form 5624 R step 2

3. This third step should be fairly easy, FULL CERTIFICATION WITH LABEL, PROVISIONAL CERTIFICATION WORK, DATE INSPECTED YYYYMMDD, NEXT INSPECTION DUE YYYYMMDD, INSPECTED BY Print or Type, GRADERANK, SIGNATURE, DA FORM R MAY, PREVIOUS EDITIONS ARE OBSOLETE, Page of, and APD LC vES - these fields has to be completed here.

Filling in part 3 in Da Form 5624 R

People often get some points wrong while filling out PREVIOUS EDITIONS ARE OBSOLETE in this section. Remember to double-check everything you enter right here.

Step 3: Go through all the information you've inserted in the blanks and then click on the "Done" button. Right after registering a 7-day free trial account with us, you'll be able to download the completed form or send it through email right off. The PDF will also be readily available through your personal account menu with each change. We do not share any details that you type in whenever filling out documents at our site.

Tips for Accurate Completion

Inspectors filling out the defibrillator inspection record for the first time should gather the following before starting: the unit's manufacturer documentation, the model and serial numbers from the equipment label, and the previous inspection report if one is available. Having this information ready prevents errors and reduces the time needed to complete each section accurately.

Pay close attention to the certification outcome fields at the bottom of the form. Selecting Full Certification with Label certifies that the unit passed all tests and is cleared for active deployment. Selecting Provisional Certification requires completing the corrective action work field before the form is considered complete. Both the inspection date and the next inspection due date must be entered in YYYYMMDD format to avoid processing delays.

Frequently Asked Questions

What is the DA Form 5624 R used for?
It is the U.S. Army's official record for documenting defibrillator inspections at military medical facilities. Inspectors use it to record the results of visual checks and performance tests, and to certify whether each unit meets required standards for safe operation.

Who is authorized to sign this inspection record?
The form must be signed by the authorized inspecting technician or officer who physically performed the inspection. The inspector's grade or rank is also required in the designated field alongside the printed name.

How often must this inspection be completed?
Inspection frequency follows the maintenance schedule defined by the unit's equipment management plan and the manufacturer's recommended intervals. The form includes a Next Inspection Due field to help track upcoming inspection deadlines and maintain a consistent schedule.

Are there other related inspection and maintenance forms?
Yes. Medical maintenance teams often work with the Inspection Authorization Activity Record for broader equipment authorization workflows. For other Army preventive maintenance documentation, the DA Form 5019 R is commonly used alongside this inspection record.

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