Project ADAM Greater Cincinnati Intake Form

Project ADAM Greater Cincinnati Intake Form

This form should be completed by a school nurse, healthcare administrator, athletic trainer, or organization leader. If you are a parent and/or community member, please share this form with the appropriate contact at the school/organization you are affiliated with to arrange for them to complete and submit.

This intake form will provide us with an initial assessment of your current cardiac emergency preparedness and identify any gaps or support needed to help your school/organization achieve Heart Safe certification by Project ADAM Greater Cincinnati.

There are no wrong answers and this information will be used to develop next steps and action items.

Once you submit the form, a member of our team will reach out within 10 business days with additional information.

Thank you for your interest in partnering with Project ADAM!

Today's date*

Name of person completing form*

School or organization name*

District name (if affiliated with a district)

Skip if you are not part of a school district

Other (Explain)*

Contact person for your school/organization*

Job title of contact person*

E-mail address*

Phone number*

# of students/people in your school/organization*

Average number of people in your building on a typical day

How many separate buildings are on your campus?*

Automated External Defibrillators (AEDs)

This section will collect information about the current status of AEDs at your school/organization.

Does your school/organization have an AED?*

Select

If you do not have an AED, is there a reason?*

Have you attempted to get one without success or been told that there are barriers to having an AED at your location?

Select

Please share additional information*

How many AEDs do you have (including athletics)?*

Where are the AEDs located?*

Are any of the AED locations locked?*

Select or enter value

Please explain locked locations

Our AED(s) have clear signage*

Select

Our AED(s) are monitored for readiness regularly*

AED(s) should be checked for performance readiness at least monthly, or per manufacturer’s directions and documented each time

Select

Each AED has a first responder kit nearby*

A first responder kit includes: CPR barrier device, scissors, gloves, razor, and towel. This should be attached to the AED or nearby.

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Cardiac Emergency Response Team (CERT)

We have a CPR-AED site coordinator identified*

A CPR-AED Site Coordinator oversees the CPR-AED program activities and training.

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We have a designated CERT?*

A designated CERT should be comprised of approximately 5-10 people (or 10% of staff in a smaller organization).

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How many people are on your CERT?*

A designated Cardiac Emergency Response Team (CERT) should be comprised of at least 10% of staff or approximately 5-10 people.

Cardiac Emergency Response Plan (CERP)

We have a written CERP*

A CERP consists of all the steps your response team will take in the event of a cardiac emergency, from communicating with 911 to performing CPR/AED tasks, and controlling the crowd.

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Our CERP is reviewed annually*

Cardiac Emergency Response Plan (CERP)

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We have a cardiac emergency communication code

A cardiac emergency communication code is used to notify responders and others in the area that an incident is occurring.

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When outside, staff carry a communication device*

For example, do staff members carry cell phones when outside for recess?

Select

Local EMS know about our CERP*

Emergency Medical Services (EMS), Cardiac Emergency Response Plan (CERP)

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Outside groups use our facilities after hours*

Do any other groups use your facilities after hours for practice or community meetings?

Select

Our CERP has been shared with outside groups*

Cardiac Emergency Response Plan (CERP). Do these groups know where the AEDs are located and how to access them?

Select

Training/Education

Our CERT is updated on training every two years*

CPR-AED training for the Cardiac Emergency Response Team (CERT) is updated at least every two years. Project ADAM recommends CPR-AED certifications are updated every two years or Hands-Only CPR-AED trainings are updated annually.

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We have a system to track this training*

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All faculty/staff know where the AEDs are located*

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All faculty/staff know how to access AEDs*

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Faculty/staff are educated about SCA annually*

Faculty/staff should receive annual education related to SCA awareness and the organization’s CERP.

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We conduct an annual AED drill to test our plan*

Heart Safe certification requires at least one annual cardiac emergency response drill. Project ADAM helps run these drills, using a checklist we share. We also help debrief staff after the drill.

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How did you hear about Project ADAM?

Other comments about your program

Please provide any additional information you would like to share with our team.

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