The code block below illustrates how one might use # and // as comments in your logic and calculations.

# Text can be put here to explain what the logic/calculation does and why.
if ([field1] = '1' and [field2] > 7,

	// This comment can explain what the next line does.
	[score] * [factor],

	// Return '0' if the condition is False.
	0
)

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Stage:

Initial application/checklist

AED Incident form

AED Replacement Pads form

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Survey Date (auto-populated, not seen on public survey)
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M-D-Y

Heart Safe School Program Checklist

The Heart Safe School program is a comprehensive program through Children's Healthcare of Atlanta's Project S.A.V.E. The program aims to ensure sudden cardiac arrest preparedness in schools to protect students, staff and visitors in the event of a cardiac emergency.

Instructions:
This form is used as an initial assessment of your school's cardiac emergency preparedness to become a Heart Safe School and should be completed by the site coordinator for your school.

Please complete one checklist form for each school that would like to receive Heart Safe School designation.

If you are unable to complete this form, you may click "save and return later", and complete the form at any time. You will be provided with a code to use to return to the form where you left off. Please make sure to write down this code.

Once all checklist criteria have been met, please submit this form. Please retain a copy for your school files. Someone from the Project S.A.V.E team will review it within 30 days of submission. We will follow up with any questions.

Once approved, the Heart Safe School designation is for 2 years. There is no cost for schools to apply or receive designation.

Thank you,
Children's Healthcare of Atlanta Project S.A.V.E. Team
ProjectSAVE@choa.org

First name:

* must provide value

Last name:

* must provide value

Email:

* must provide value

Phone number:

* must provide value

What is your role?

* must provide value

Administrator

Athletic Director/Trainer

School Nurse

Teacher

Other (please specify):

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Is this application for an individual school or part of a District level application?

Please note, this form must be completed for each school seeking designation.

* must provide value

Individual school

District level

I don't know/unsure

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Type of school:

* must provide value

Public

Private

Other (please specify):

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School level of education (select all that apply):

* must provide value

Pre-School

Elementary School

Middle School

High School

School name:

* must provide value

Other school name:

* must provide value

Main school phone number:

* must provide value

Address:

* must provide value

City:

* must provide value

State:

* must provide value

County:

* must provide value

County:

* must provide value

District:

* must provide value

Principal's name:

* must provide value

Principal's email:

* must provide value

Please indicate the approximate number of each of the following for your school:

Students:

* must provide value

Staff:

* must provide value

Buildings:

* must provide value

Modular/portable buildings:

* must provide value

Do you have a certified CPR/AED Instructor on staff?

* must provide value

Yes

I don't know/unsure

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How many certified CPR/AED Instructors do you have on staff?

* must provide value

Instructor first name:

* must provide value

Instructor last name:

* must provide value

Instructor email:

* must provide value

Instructor first name:

* must provide value

Instructor last name:

* must provide value

Instructor email:

* must provide value

Instructor first name:

* must provide value

Instructor last name:

* must provide value

Instructor email:

* must provide value

Instructor first name:

* must provide value

Instructor last name:

* must provide value

Instructor email:

* must provide value

Instructor first name:

* must provide value

Instructor last name:

* must provide value

Instructor email:

* must provide value

Instructor first name:

* must provide value

Instructor last name:

* must provide value

Instructor email:

* must provide value

Instructor first name:

* must provide value

Instructor last name:

* must provide value

Instructor email:

* must provide value

Instructor first name:

* must provide value

Instructor last name:

* must provide value

Instructor email:

* must provide value

Instructor first name:

* must provide value

Instructor last name:

* must provide value

Instructor email:

* must provide value

Instructor first name:

* must provide value

Instructor last name:

* must provide value

Instructor email:

* must provide value

Yes

The school has an AED(s).

* must provide value

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AED(s) location(s) are accessible from any area on school campus making it possible to retrieve AED, apply pads and deliver a shock (if needed) within 2-3 minutes.

* must provide value

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AED(s) have clear signage throughout the school campus.
*Signage should be visible and protrude from the wall.

* must provide value

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AED(s) are checked monthly or per manufacturer's guidelines and documented each time.

* must provide value

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First responder kit(s) are located near or attached to the AED which includes: CPR barrier device, scissors, gloves, razor, and towel.

* must provide value

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How many AEDs do you have?

* must provide value

Yes

We have a site coordinator identified who oversees the overall program.

* must provide value

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We have a designated cardiac emergency response team comprised of at least 10% of staff or 5 to 10 people with current CPR/AED certification. Documentation identifying team members is maintained.

* must provide value

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How many staff members comprise the Cardiac Emergency Response Team?

* must provide value

Yes

We have a written Cardiac Emergency Response Plan reviewed at least annually with staff.

* must provide value

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We have a written Cardiac Emergency Response Plan for each building and sports facility.

* must provide value

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The Cardiac Emergency Response Plan and location of AED(s) are communicated to all groups using the school for organized after-school activities or sports.

* must provide value

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We have a cardiac emergency communication code (overhead or other) to notify responders and others that an incident is occurring. Staff outside should always carry a communication device.

* must provide value

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Yes

We have a system in place to track CPR/AED training and retraining for the Cardiac Emergency Response Team.
*Certification is updated at least every two years.

* must provide value

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Do you need help with CPR/AED training at your school?

* must provide value

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All faculty and staff know the location of the AEDs and how to access them.

* must provide value

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All faculty and staff have annual education and awareness training on sudden cardiac arrest (warning signs, recognition, communication procedure and Cardiac Emergency Response Plan).

* must provide value

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Yes

We conduct at least one annual AED drill to test our Cardiac Emergency Response Plan, emergency responders and communication procedures.

* must provide value

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An AED drill summary checklist is utilized for planning and post drill review.

* must provide value

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Download and complete the Cardiac Emergency Response Drill here.

Date of the completed Cardiac Emergency Response Drill:

* must provide value

M-D-Y

Please upload the completed Cardiac Emergency Response Drill here:

* must provide value

Upload file

Acknowledgement Statement:

Implementation of a Project S.A.V.E. Heart Safe School program demonstrates your school's commitment and preparation to respond in the event of a cardiac emergency.

By submitting this form, I attest the information provided to be true to the best of my knowledge and approved by the school administrator.

* must provide value

Add signature

Please note, if AED is used during an emergency:

Conduct an incident debrief with your Cardiac Emergency Response Team
Complete the AED Incident Report Form
AED maintenance within 24 hours

This information can also be found on our website.

AED Incident Report Form

When to complete this form:

Please complete this form anytime the Cardiac Emergency Response Team is activated. This form should be completed for both school and community incidents.

Location of incident:

School = school or part of the school campus

Community = any location outside of a school campus

Full name of the person completing this form:

* must provide value

Email:

* must provide value

Date of incident:

* must provide value

M-D-Y

Incident location:

* must provide value

School

Community

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Community location name:

* must provide value

Community location address (street, city, zip code):

* must provide value

Type of school:

* must provide value

Public

Private

Other (please specify):

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School name:

* must provide value

Other school name:

* must provide value

County:

* must provide value

District:

* must provide value

What is your role within the school?

* must provide value

Administrator

Athletic Director/Trainer

School Nurse

Teacher

Other (please specify):

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At the time of the incident, was this school a designated Heart Safe School?

* must provide value

Yes

In progress

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Gender of the victim:

* must provide value

Male

Female

Unknown

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Age of the victim:

* must provide value

Was there an AED on site?

* must provide value

Yes

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Yes

Unknown

Was CPR provided?

* must provide value

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Was an AED brought to the scene?

* must provide value

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Was the AED turned on?

* must provide value

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Were the AED pads placed on the victim?

* must provide value

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Was an AED shock delivered?

* must provide value

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Was EMS/911 contacted?

* must provide value

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Was the patient transported to the hospital?

* must provide value

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Did the victim survive?

* must provide value

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Provide a brief description of the incident:

* must provide value

Expand

AED Replacement Pads Request Form

Thank you for your commitment to ensuring a heart safe environment within your school. Project S.A.V.E. is dedicated to supporting schools that have experienced a sudden cardiac arrest on their campus by providing AED pads free of charge through our AED Replacement Pads Program.

Please note that a request must meet one of the following criteria:

Active Heart Safe School
AED device used during a cardiac emergency incident (event)

Complete this form to receive your replacement AED pads.

Full name of the person completing this form:

* must provide value

Email:

* must provide value

Phone number:

* must provide value

School name:

* must provide value

Are you affiliated with a Heart Safe designated school?

* must provide value

Yes

Unsure

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Reason for requesting new AED pads:

* must provide value

Pads were used during an incident

Pads are expired

Pads are damaged or opened

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Were the AED pads used during an cardiac emergency incident?

* must provide value

Yes

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Did you complete the AED Incident Form?

* must provide value

Yes

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Date of incident:

* must provide value

M-D-Y

AED Brand/Manufacturer:

* must provide value

Please indicate how many pads you are requesting for each of the following:

Adult AED Pads:

* must provide value

Infant/Child AED Pads:

* must provide value

Street address:

* must provide value

City:

* must provide value

Zip code:

* must provide value

You have selected an option that triggers this survey to end right now.

To save your responses and end the survey, click the 'End Survey' button below. If you have selected the wrong option by accident and/or wish to return to the survey, click the 'Return and Edit Response' button.

Heart Safe School Program Checklist

Site Coordinator Information

School Information

CPR/AED Instructor Information

Automated External Defibrillators (AEDs)

Cardiac Emergency Response Team

Cardiac Emergency Response Plan

Training/Education

Cardiac Emergency Response Drills

AED Incident Report Form

AED Replacement Pads Request Form

AED Pads Shipping Information:

You have selected an option that triggers this survey to end right now.