American Heartsaver Recognition Program

RECOGNITION FORM

New Jersey 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 and American Stroke Association, the largest voluntary health organization dedicated to improving the health of all Americans while 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 (e.g. sudden cardiac arrest). Their efforts include: ♦ Immediate recognition and calling 9-1-1; ♦ performing cardiopulmonary resuscitation (CPR); ♦ or using an automated external defibrillator (AED). 2. 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 which will be held on June 4, 2014 at the Conference Center at Robert Wood Johnson Hamilton Center for Health & Wellness in Mercerville, NJ. 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 ceremony. Award selections made by the committee are final. Eligibility ♦ Recognition Forms submitted for the NJ 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 Jersey within the January 2012-present day timeframe. ♦ Anyone who performs CPR or defibrillation, who has acted in a good faith effort or who has been CPR/AED certified by the American Heart Association or other generally accepted organization’s 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 experience included in American Heart Association promotional materials and be willing to participate in publicity/media efforts to promote the American Heart Association efforts in supporting the Chain of Survival.

Heartsaver The American Heartsaver Recognition Program is an initiative Chain of Survival supporting the American Heart Association’s efforts to strengthening the Chain of Survival in our communities as an The American Heart Association Chain of Survival is a critical effort to improve the cardiovascular health of all Americans four-step process that can mean the difference between life while reducing death and disability from heart disease and and death for someone experiencing sudden cardiac arrest, stroke by 20% by the year 2020. Nearly 424,000 people have heart attack or stroke, as well as other medical emergencies cardiac arrest outside of a hospital every year, and only such as choking and drowning. The five critical steps or “links” 10.4% survive. Given right away, CPR doubles or triples in the Chain of Survival include: survival rates and executing the Chain of Survival can save ♦ Link # 1: Early Access (know the warning signs of thousands of lives annually. The Chain of Survival is only sudden cardiac arrest, heart attack and stroke and call 9- as strong as its weakest link. 1-1 immediately) ♦ Link # 2: Early Cardiopulmonary resuscitation (CPR) ♦ Link # 3: Early Defibrillation ♦ Link # 4: Early Advanced Care ♦ Link # 5: Integrated post-cardiac arrest care

American Heartsaver Recognition Form For more information contact the Association: (609) 223-3734 Return completed Recognition Form to: American Heart Association- Attn: Courtney Nelson, 1 Union Street, Suite 301, Robbinsville, NJ 08691 [email protected] 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: Wednesday April 30, 2014

Name: ______Age (at time of rescue/activity): __ Mailing Address: ______City: ______State: ______Zip: ______Home address if different from above: ______Daytime Phone (work): ______Home Phone: ______Cell: ______Email: ______Occupation: ______Employer: ______Had the person/group received CPR or AED training? Yes No N/A Was training from an American Heart Association course? Yes No N/A If no, who was the source of the training? ______Date and site of CPR/AED training (if known): ______

Name: ______Age (at time of rescue/activity): __ Mailing Address: ______City: ______State: ______Zip: ______Home address if different from above: ______Daytime Phone (work): ______Home Phone: ______Cell: ______Email: ______Occupation: ______Employer: ______Had person/group received CPR or AED training? Yes No N/A Was training from an American Heart Association course? Yes No N/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, testimonials or other supporting documents verifying the details. Link #1 – Was 9-1-1 called? Yes No By Whom? Link #2 – Was CPR performed? Yes No By Whom? Link #3 – Was defibrillation performed? Yes No By Whom? Link #4 – Was advanced medical care on the scene? Yes No By Whom? Link #5 – Was post-cardiac arrest care completed? Yes No By Whom? Did the person survive? Yes No Don’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: ______Cell: ______Email: ______Date of Cardiac Emergency (m/d/y): ______Location: ______

Describe in some detail the extraordinary rescue effort or effort made to strengthen the Chain of Survival: ______PLEASE ATTACH UP TO 2 ADDITIONAL SHEETS IF MORE SPACE IS 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.

______Signature Today’s Date