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Project ADAM Texas Annual Heart Safe School Submission Form

Thank you for staying active in our Heart Safe School program! As a small token of our appreciation for keeping your school Heart Safe, we're pleased to offer a Heart Safe School sticker to proudly display on your Heart Safe School banner. Please submit the following information to receive your sticker.

Note: In order to receive the sticker, you must be doing all 5 of the annual requirements. In addition, we require resubmission of your Heart Safe School Checklist every 3 years. There will be a place on this form for you to upload or fill out the checklist if this applies to your school. All requirements must be in place. Should you require assistance with any of the below requirements or have any questions/concerns, you're welcome to email ProjectAdamTexas@cookchildrens.org or call us at (682) 885-6755.

This form MUST be submitted prior to 12/31 at 11:59 pm every year in order to receive your annual Heart Safe School sticker.

Your first name:

Your last name:

Your email:

Your phone number:

School name:

Please type the full name of your school to choose it from the list. If your school is not listed, please choose "Other/Not listed" and type your school in the open text box.

School district:

School:

* must provide value

Annual requirement 1:

We have reviewed our school's written Cardiac Emergency Response Plan and made any necessary adjustments/modifications as necessary.

* must provide value

Yes

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Did you mean to answer "no"? If not, you can change it to "yes."
(Reminder: all requirements must be answered "yes" in order to receive a sticker.)

If you do answer "no," please email ProjectAdamTexas@cookchildrens.org or call us at (682) 885-6755 if assistance is needed to meet this requirement.

Annual requirement 2:

We have conducted at least 1 AED Drill this calendar year.

Note: An AED Report Form may only be used in lieu of the AED Drill Checklist if CPR was provided, the AED was turned on, and the pads were applied. The event must fall within this calendar year.

* must provide value

Yes - need to upload or fill out form

Yes - filled out online form earlier this calendar year

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Would you like to upload your AED Drill Checklist or fill out an AED Drill Checklist online after completing this form?

* must provide value

Upload my AED Drill Checklist or AED Report Form

Fill out an AED Drill Checklist online

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Which form do you want to fill out?

* must provide value

Drill Checklist Project ADAM

Cook Children's Texas Project ADAM AED Drill Checklist

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AED Drill checklist or AED Report Form*

*AED Report Form may only be used if CPR was provided and the AED was turned on with pads applied. The event must fall within this calendar year.

* must provide value

Upload file

Annual requirement 3:

We check our AED monthly/per manufacturer directions and document each check. Please note, you are not required to upload your AED maintenance checklist(s) for this requirement.

* must provide value

Yes

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Annual requirement 4:

We have provided annual education on sudden cardiac arrest (SCA) awareness, signs and how to recognize SCA (sudden collapse and unresponsive; victim may have initial seizure-like or continued respiratory movements) to all faculty and staff.

* must provide value

Yes

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Annual requirement 5:

CPR-AED training for the Cardiac Emergency Response Team (CERT) is current and there is a system in place to track retraining.

* must provide value

Yes

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Mailing address for your Heart Safe School sticker:

* must provide value

Expand

Has it been 3 years since you submitted your Heart Safe School Checklist to Project ADAM?

* must provide value

Yes

Unsure

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I would like to:

* must provide value

Upload my Heart Safe School Checklist

Fill out a Heart Safe School Checklist

Have someone contact me

Upload your Heart Safe School Checklist here:

* must provide value

Upload file

Upload your Heart Safe School Checklist here (page 2 if needed):

Upload file

Date of submission:

* must provide value

M-D-Y H:M

You have answered 'No' to one or more annual requirements. This makes you ineligible for a Heart Safe School sticker this calendar year until all requirements are met.

You can choose to submit this form later once all requirements are met (by 12/31 of this year) or you can contact us for further assistance.

Please note:

Forms submitted AFTER 12/31 do not count for the current school year; they count for the calendar year submitted beginning 1/1.

Once you click "Submit" below, a PDF of your responses will be emailed to you for your record. Please ensure the correct email and school information is entered.

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.

Project ADAM Texas Annual Heart Safe School Submission Form

This form MUST be submitted prior to 12/31 at 11:59 pm every year in order to receive your annual Heart Safe School sticker.

You have answered 'No' to one or more annual requirements. This makes you ineligible for a Heart Safe School sticker this calendar year until all requirements are met.

You can choose to submit this form later once all requirements are met (by 12/31 of this year) or you can contact us for further assistance.

Please note:Forms submitted AFTER 12/31 do not count for the current school year; they count for the calendar year submitted beginning 1/1.

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

Please note:

Forms submitted AFTER 12/31 do not count for the current school year; they count for the calendar year submitted beginning 1/1.