HEARTSafe Workplace Application

Name of business seeking designation:

Business Mailing Address:

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Business Primary Contact:

First

Last

Phone Number:

Ext:

Email Address:

Confirm email

Must meet all criteria:

Current CPR/AED training and certification requirement: a minimum of 10% of total work force must be trained in CPR. Free training is available through Erie County. Visit www.erie.gov/CPR for more information.
AED requirements: at least one AED must be available on-site, positioned in a publicly accessible area, and clearly marked with an AED identification sign. Companies are encouraged to have sufficient AEDs to allow one to be available within 4 minutes anywhere within the organization. Provide a list of specific locations of all AEDs, including address, building name, floor, etc.
Written Cardiac Emergency Response Plan: a clear, well-documented, and regularly practiced plan that outlines procedures for responding to medical emergencies and includes protocols for AED maintenance. Please provide copy of plan.

Yes, a minimum of 10% of our total work force is trained in CPR.

Yes, at least one AED is available on-site, positioned in a publicly accessible area, and clearly marked with an AED identification sign.

Provide a list of specific locations of all AEDs, including address, building name, floor, etc.

One file only.
2 MB limit.
Allowed types: txt, rtf, pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods.

Yes, we have a written cardiac emergency response plan.

Written Cardiac Emergency Response Plan

Please provide copy of a clear, well-documented, and regularly practiced plan that outlines procedures for responding to medical emergencies and includes protocols for AED

One file only.
2 MB limit.
Allowed types: txt, rtf, pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods.

Applicant Signature:

Please sign above.

Printed Name

Title

Date