School Year Beginning Fall of
School Name
* must provide value
School Grade
* must provide value
Elementary Junior High High School
School District
* must provide value
Example formatting "Houston ISD, Pearland ISD, etc."
School Address
* must provide value
Example formatting "6621 Fannin St, Houston, TX 77030"
Step 1 Has CPR/AED site coordinator been identified?
* must provide value
Yes
No
Please indicate your school's Project ADAM Site Coordinator
* must provide value
Please provide your Project ADAM Site Coordinator's e-mail address.
* must provide value
Please provide your Project ADAM Site Coordinator's phone number.
* must provide value
Does your school's Project ADAM Site Coordinator certify that an AED is accessible from any part of the campus within 2-3 minutes?
* must provide value
Yes
No
Does your school need a new AED?
Yes
No
Schools may need a new AED if they dont have enough to access one from any part of the campus within 2-3 minutes. They may also need one if one or more of their AEDs is more than 8 years old.
Does your school's Project ADAM Site Coordinator certify that there is clear signage throughout the campus indicating where the AED(s) are located?
* must provide value
Yes
No
Signage should stick out from the wall so that someone coming down the hall can see where the AED is.
If possible, please upload a picture of your campus's directional signage.
Has the school identified members of the Cardiac Emergency Response Team (CERT)?
* must provide value
Yes
No
Cardiac emergency response team member 1
* must provide value
Cardiac emergency response team member 1 title
* must provide value
Coach, Nurse, English Teacher, etc.
Cardiac emergency response team member 1 contact
* must provide value
Cardiac emergency response team member 2
* must provide value
Cardiac emergency response team member 2 title
* must provide value
Coach, Nurse, English Teacher, etc.
Cardiac emergency response team member 2 contact
* must provide value
Cardiac emergency response team member 3
* must provide value
Cardiac emergency response team member 3 title
* must provide value
Coach, Nurse, English Teacher, etc.
Cardiac emergency response team member 3 contact
* must provide value
Cardiac emergency response team member 4
* must provide value
Cardiac emergency response team member 4 title
* must provide value
Coach, Nurse, English Teacher, etc.
Cardiac emergency response team member 4 contact
* must provide value
Cardiac emergency response team member 5
* must provide value
Cardiac emergency response team member 5 title
* must provide value
Coach, Nurse, English Teacher, etc.
Cardiac emergency response team member 5 contact
* must provide value
Does your Project ADAM Site Coordinator certify that your cardiac emergency response team has been trained in CPR and AED usage?
* must provide value
Yes
No
1
2
3
If you need help with CPR training for students, what grade(s) are they in?
Does your Project ADAM Site Coordinator certify that there is a tracking system in place to ensure that team member training remains current?
* must provide value
Yes
No
Does your Project ADAM Site Coordinator certify that ALL faculty and staff know where the AED(s) are located, and how to access them?
* must provide value
Yes
No
How many AEDs are installed on your campus?
* must provide value
How many mobile AEDs (if any) does your campus have?
Mobile AEDs are not affixed to the wall. They are generally brought along with traveling sports teams.
Approximately how many faculty, staff, and students are on your campus?
Does your Project ADAM Site Coordinator certify that all faculty and staff have received annual awareness training on sudden cardiac arrest, and the school's emergency response plan?
* must provide value
Yes
No
Training should include recognition of sudden cardiac arrest, warning signs, communication procedures, and other staff roles.
Does your Project ADAM Site Coordinator certify that your school has an established cardiac emergency communication code to notify responders, and others in an area, that an incident is occurring?
* must provide value
Yes
No
Example: "Code ADAM in the cafeteria"
Has your school identified an emergency communication code?
* must provide value
Yes
No
What is your school's cardiac emergency communication code?
* must provide value
Example: "Code AED in (insert location)"
Does your communication plan cover outside areas?
* must provide value
Yes
No
Example: Staff and students on the playground or sports field.
Does your Project ADAM Site Coordinator certify that monthly maintenance checks are performed on all AED(s)?
* must provide value
Yes
No
Does your Project ADAM Site Coordinator certify that each AED unit has a responder kit near or attached to it?
* must provide value
Yes
No
This kit includes items such as scissors, gloves, razors,towels, CPR barrier devices, alcohol wipes, etc.
Does your Project ADAM Site Coordinator certify that your school conducts at least two cardiac response drills each year?
* must provide value
Yes
No
Ideally there would be one drill per semester.
Please provide the date of the first planned or completed AED drill for this school year.
Today M-D-Y
Please provide the date of the second planned or completed AED drill for this school year.
Today M-D-Y
Has your school created a written cardiac response plan?
* must provide value
Yes
No
Does your Project ADAM Site Coordinator certify that your school's written cardiac emergency response plan is reviewed annually?
* must provide value
Yes
No
Please upload your school's Cardiac Emergency Response Plan.
Does your Project ADAM Site Coordinator certify that your school's cardiac emergency plan has been shared with the local emergency medical services (EMS)?
* must provide value
Yes
No
Texas Children's can provide a letter that you can give to your local EMS contact, explaining what Project ADAM is and how it works. In most cases they may already know.
Does your Project ADAM Site Coordinator certify that your school's cardiac emergency plan has been shared with others that use your facilities?
* must provide value
Yes
No
Extra curricular activities, community groups, summer programs and after school usage.
Has school previously been recognized as a Texas Children's Project ADAM Heart Safe School?
* must provide value
Yes
No
Please indicate the approximate date of previous designation as a Project ADAM Heart Safe School.
Today M-D-Y
Are you applying to renew your Heart Safe School designation for the current school year?
Yes
No
Approved
Incomplete
Today M-D-Y
Name
Please initial and date notes
Has school received a Texas Children's Project ADAM Heart Safe School banner?
* must provide value
Yes
No
Number of checklist steps complete
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