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?

4. Company or Organization

4. What is the accomplishment you are recognizing the individual for?

Other

5. Are you an employee of this company or organization?

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

6. Please describe

6. Please mark the activities that best describe your organization's accomplishment

Other

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?

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.)

Other

8. Rescuer(s) status during incident?

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 Rule

10. Survivor Full Name

Survivor First NameSurvivor Last Name

11. Age at time of incident

12. Gender

13. Ethnicity

14. Type of Incident

15. Brief description of incident

16. Location of incident

Other

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

Rescuer Email

example@example.com

Rescuer Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Please include any notes or additional information the form did not ask