Recognition Form

Recognition Form

RECOGNITION FORM

New York City

American Heartsaver

Recognition Program

Presented by

American Heart Association

Working to Strengthen the American Heart Association Chain of Survival

American Heartsaver Recognition Program

The American Heart Association, the largest voluntary health organization fighting heart disease, stroke and other cardiovascular diseases, recognizes and honors the following as an American Heartsaver:

  1. Individuals who make a rescue effort to save the life of someone experiencing a cardiac emergency (i.e. sudden cardiac arrest). Their efforts include:

♦calling 9-1-1;

♦performing cardiopulmonary resuscitation (CPR);

♦or using an automated external defibrillator (AED).

  1. People, organizations and businesses that take extraordinary steps to strengthen the American Heart Association Chain of Survival, for example:

♦a school that has implemented a CPR training requirement as part of their Health Curriculum, or holds an annual CPR training day for teachers, students and families

♦a bank that places AEDs in all of its branch offices or a corporation that trains its employees in CPR and defibrillation

♦a physician who donates several AEDs to local police and educates the community about the importance of CPR.

By completing the American Heartsaver Recognition Form, each individual or group recognized on the form will receive an official letter of recognition from the American Heart Association. In addition, each form submitted will be considered for additional recognition at the American Heart Association’s event…the American Heartsaver Awards.

A committee of volunteers for the American Heart Association reviews all American Heartsaver Recognition Forms. American Heartsaver Awards are selected by the committee and publicly presented by the American Heart Association. Award recipients, family members and friends, community leaders, cardiac emergency survivors and members of the media will be invited to the ceremonies. Award selections by the committee are final.

Eligibility

♦Recognition Forms submitted for the American Heartsaver Recognition Program should be for rescue efforts or extraordinary efforts to strengthen the American Heart Association Chain of Survival made by individuals (children or adults), organizations and businesses in New York City (see examples above).

♦Anyone who performs CPR or defibrillation must have been trained according to American Heart Association or other generally accepted organizations’ guidelines.

♦All individuals involved in a rescue effort will be recognized regardless of the outcome of the person experiencing the cardiac emergency.

♦Police/security, fire/rescue and EMS/medical professionals are eligible for recognition while on or off duty as part of an extraordinary or unusual effort.

♦All individuals or groups recognized should be willing to have their “story” included in American Heart Association promotional materials and be willing to participate in publicity/media efforts to promote the American Heartsaver Recognition Program.

Heartsavers

The American Heartsaver Recognition Program is an initiative of the American Heart Association’s efforts dedicated to strengthening the Chain of Survival in our communities. Sudden cardiac arrest claims nearly 250,000 lives each year.

Nationally, the average cardiac arrest survival rate is estimated to be only five percent. The American Heart Association estimates that strengthening each community’s Chain of Survival can save at least 40,000 lives each year in the United States. The Chain of Survival is only as strong as its weakest link.

Chain of Survival

The American Heart Association “Chain of Survival” is a critical four-step process that can mean the difference between life and death for someone experiencing sudden cardiac arrest, heart attack or stroke, as well as other medical emergencies such as choking and drowning. The four critical steps or “links” in the Chain of Survival include:

Link # 1: Early Access (know the warning signs of sudden cardiac arrest, heart attack and stroke and call 9-1-1 immediately)

Link # 2: Early CPR

Link # 3: Early Defibrillation (an electrical shock to the heart to restore normal heart rhythm)

Link # 4: Early Advanced Care (medical help on the scene of the emergency because 9-1-1 was called)

American Heartsaver

Recognition Form

For more information contact an American Heartsaver Representative:

(212) 878-5900

Return completed Recognition Form to:

American Heart Association, American Heartsaver 122 East 42nd Street, 18th Floor, New York, NY 10168

• 212-850-5235 Fax

Please type or print clearly. Only answer questions that apply to your recognition request.

If more than three individuals/groups recognized, copy this form and attach additional documentation.

PLEASE RETURN THE APPLICATION BY: Friday, May 31, 2013

Name (first recognized): ______Age (at time of rescue/activity): ___

Mailing Address: ______

City: ______State: ______Zip: ______

Home address if different from above: ______

Daytime Phone (work): ______Home Phone: ______

Fax: ______Email: ______

Occupation: ______Employer: ______

Had the person/group received CPR or AED training (circle correct answer)?YesNoN/A

Was training from an American Heart Association course (circle correct answer)?YesNoN/A

If no, who was the source of the training? ______

Date and site of CPR/AED training (if known): ______

Name (second recognized): ______Age (at time of rescue/activity): ___

Mailing Address: ______

City: ______State: ______Zip: ______

Home address if different from above: ______

Daytime Phone (work): ______Home Phone: ______

Fax: ______Email: ______

Occupation: ______Employer: ______

Had the person/group received CPR or AED training (circle correct answer)?YesNoN/A

Was training from an American Heart Association course (circle correct answer)?YesNoN/A

If no, who was the source of the training? ______

Date and site of CPR/AED training (if known): ______

Name (third recognized): ______Age (at time of rescue/activity): ___

Mailing Address: ______

City: ______State: ______Zip: ______

Home address if different from above: ______

Daytime Phone (work): ______Home Phone: ______

Fax: ______Email: ______

Occupation: ______Employer: ______

Had person/group received CPR or AED training (circle correct answer)?YesNoN/A

Was training from an American Heart Association course (circle correct answer)?YesNoN/A

If no, who was the source of the training? ______

Date and site of CPR/AED training (if known): ______

Description

Please describe below the rescue effort or extraordinary effort made to strengthen the Chain of Survival. Include details that will explain where and how the event occurred, and the action taken by the individual(s) or groups involved. Detailed information is important. Attach any news articles, police statements, medical reports or other documents verifying the details. If more space is needed, please attach a separate sheet.

Link #1 – Was 9-1-1 called? Yes NoBy Whom?

Link #2 – Was CPR performed? Yes NoBy Whom?

Link #3 – Was defibrillation performed? Yes No By Whom?

Link #4 – Was advanced medical care on the scene?Yes NoBy Whom?

Did the person survive?Yes NoDon’t Know

If person survived, what is present condition? ______

Name of Cardiac Emergency

Survivor (if available):______Age (at time of rescue): ______

Mailing Address: ______

City: ______State: ______Zip: ______

Daytime Phone (work): ______Home Phone: ______

Fax: ______Email: ______

Occupation: ______Employer: ______

Date of Cardiac Emergency (mo/day/yr): ______Location: ______

Please describe in some detail the rescue effort or effort made to strengthen the Chain of Survival: ______

______

______

______

______

______

______

______

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PLEASE ATTACH AN ADDITIONAL SHEET IF NEEDED.

Person Submitting Recognition Form

Name: ______Age: ______

Mailing Address: ______

City: ______State: ______Zip: ______

Daytime Phone: ______Email: ______

How did you know about this save, attempted save or activity to strengthen the Chain of Survival? ______

______

I attest to the accuracy and validity of all information contained within this recognition form. I understand that information contained within this form may be verified by a member of the American Heartsaver committee or by an American Heart Association staff member, and that all awards decisions are final.

______

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