Heart Hero Oregon

Heart Hero Oregon
We know Oregonians are making a difference in cardiovascular health across the state - personally, professionally, and in emergency settings. Please fill out the form so we can recognize your Heart Hero for their accomplishments.
1. Submitter First & Last Name*

First NameLast Name
2. Email*
example@example.com
3. Are you recognizing an organizational or individual accomplishment?*

OrganizationIndividual(s)
4. Company or Organization*
4. What is the accomplishment you are recognizing the individual for?*

Lifestyle ChangeCPR & Emergency ResponseOther
5. Are you an employee of this company or organization?*

YesNo
5. Please provide the first and last name of the individual you are recognizing*

First NameLast Name
5. Please mark the activities that best describe your Heart Hero's accomplishment*

Recognized warning signs of a cardiac emergencyLocated and used an AEDPerformed CPRCalled emergency servicesOther
6. Please describe*
6. Please mark the activities that best describe your organization's accomplishment*

Implementation of a blood pressure monitoring stationImplementation of a cardiac emergency response planPlacement of an AEDBystander CPR education for employeesCPR certification for employeesDevelopment of a healthy food policy for catering and meal offeringsOther
6. Rescuer First & Last Name (if multiple, please separate names with a comma)*
7. Briefly describe the changes made and the impact it has had*
7. Were the Rescuers trained through the AHA?*

YesNoUnknown
8. Can we contact you if we have any questions? (If there is another individual we should speak with about this, please include their information in the Other field below.)*

YesNoOther
8. Rescuer(s) status during incident?*

Bystander/StrangerTeacher/Student/School StaffEMS/ParamedicPolice/FirefighterFamily MemberDoctor/Nurse/Hospital WorkerColleagueTelecommunicatorOther
9. Survivor Information (Survivor Information isn’t required but helps ongoing learning about cardiac events)

I hereby certify I am not an employee or representative of, a “covered entity” under the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”). Or that I am, or represent, a covered entity and have obtained the right to release “protected health information” concerning the survivor named in this report. If you are, or represent, a “covered entity” and do not have permission to release the information, do not complete survivor section of this report subject to the Privacy RuleDisagree
10. Survivor Full Name

Survivor First NameSurvivor Last Name
11. Age at time of incident
12. Gender

MaleFemaleOther
13. Ethnicity

African AmericanAsianCaucasianHispanicNative AmericanOther
14. Type of Incident

Cardiac Arrest/Heart AttackStrokeDrowningChokingOther
15. Brief description of incident
16. Location of incident*

HomeWorkSchoolOther
Would you or the individual you're recognizing like to be spotlighted or contacted?*

YesNo
Rescuer Email
example@example.com
Rescuer Phone Number
Please enter a valid phone number.
Please include any notes or additional information the form did not ask
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