HEARTSAFE PROGRAM APPLICATION AND AGREEMENT

Sudden cardiac arrest suffered outside the hospital setting is responsible for approximately 350,000 deaths annually in the United States. Of those victims approximately 5,000 -7,000 are children. Defibrillation is the only effective treatment for sudden cardiac arrest. Early defibrillation can mean the difference between life and death, an active and healthy life or a vegetative state. An Automated External Defibrillator (AED) is a small, portable device that analyzes heart rhythms. It offers the user voice-prompted instructions and, if determined to be necessary, can deliver a potentially lifesaving shock to a victim in cardiac arrest. An AED will not deliver a shock to anyone who is not in sudden cardiac arrest. AEDs are easy to use, compact, battery-operated and lightweight.

Sequoia Healthcare District's HeartSafe Program makes AEDs available at a reduced rate or will donate equipment to eligible nonprofit organizations.

Steps to Become a HeartSafe Partner:

  • Complete and submit application and agreement
  • This helps HeartSafe staff become familiar with your needs and acquaints you to the Program
  • HeartSafe staff will visit your facility to meet with you and conduct site assessment
  • Wall cabinet installation by AED acquirer
  • Training and certification for staff on the use of AEDs will be coordinated by the District
  • Delivery and placement of AED(s)
  • District will register AED with the County Emergency Medical System (EMS)
  • Ongoing maintenance and training

Thank you for your interest. With the support of the community, southern San Mateo County will soon be a more heart safe place to live, work, learn and play!

For more information, please contact Pamela Kurtzman, Sequoia Healthcare District’s HeartSafe Program Coordinator, at (650) 367-5940.

After evaluating several models, Sequoia Healthcare District’s HeartSafe Program will be providing the Medtronic LIFEPAK CR Plus Automatic model.

About Sequoia Healthcare District
Headquartered in Redwood City, Sequoia Healthcare District identifies local healthcare needs and collaboratively develops solutions. District tax revenues are used for programs and activities designed to achieve health, wellness and disease prevention in southern San Mateo County. Communities in the District include Redwood City, San Carlos, Belmont, Menlo Park, Woodside, Atherton and Portola Valley.

Part 1: Applicant Information


Name of Organization ___________________________________________

Address (City, State, Zip) ___________________________________________

Phone/Fax ___________________________________________

Website ___________________________________________

Main Contact for AED Implementation ___________________________________

Title ___________________________________________

Phone/Fax ___________________________________________

Email ___________________________________________

Purpose or function of organization ___________________________________________

Description of facility/facilities

_________________________________________________________

_________________________________________________________

_________________________________________________________

# Previous cardiac incidences at this site _________________

# Employees on-site in a regular day _________________

# People the organization services in a regular day _________________

Types and sizes of any additional groups/organizations that meet at this site

___________________________________________________________

___________________________________________________________

Number of AEDS currently on site ___________________

Number of Employees CPR/AED Certified ___________________

Names of employees to receive training in the use, installation, operation, and maintenance of the AED and AED procedures

_________________________________________________________

_________________________________________________________

Name of employee to be responsible for AED training records

___________________________________________

Name of employee to be responsible for maintenance of AED

___________________________________________

Part 2: Program Costs

The Medtronic LifePak CR Plus AED unit retails for $2,495. Our discounted price is $1,595. The wall cabinets cost between $200-$300. CPR/AED training costs $50 per person. Medical authorization, which typically costs $250, is provided at no cost.

Is your organization applying for donated equipment and training? Yes*____ No____

*If applying for donated equipment and training, please attach verification of the organization’s tax-exempt status, a copy of the current year operating budget and the previous year actual budget. Please also attach a brief explanation of the need for financial assistance as it pertains to obtaining donated AED equipment and training. Nonprofit organizations with tax exempt status under Section 501(c)(3) of the Internal Revenue Code and governmental entities such as school districts, cities, and counties (or programs created by any such organization or entity) are eligible to apply for donated equipment. Preference will be given to applicants located within the District. Organizations or entities that are located outside of District boundaries must demonstrate that they serve the healthcare needs of District residents or communities served by the District.

Organizations outside Sequoia Healthcare District that do not fit the criteria as described above or any for-profit entity within or outside the District’s geography may apply for the HeartSafe Program and acquire the equipment at Sequoia Healthcare District’s greatly discounted price.

Part 3: Agreement and Acknowledgments

All HeartSafe program participants are provided with the following:

  • Medical Authorization: Sequoia Healthcare District will provide the medical authorization required for the acquisition of the AEDs (automated external defibrillators).
  • Site Assessment: The site assessment of the participant’s facilities will determine the appropriate number of AEDs, their locations, and who will be trained.
  • Coordination of Training: Sequoia Healthcare District will help determine and coordinate training for the appropriate number of personnel who must be certified in American Red Cross or American Heart Association CPR & AED skills. A brief in-service will be provided to familiarize CPR certified staff with the AED unit.
  • Policy and Procedure: Sequoia Healthcare District will make templates available for policy and procedure implementation.
  • HeartSafe Equipment: AED units and accompanying wall cabinets will be acquired through Sequoia Healthcare District.

Compliance with the following guidelines is required for all HeartSafe Program participants:

By submission of this signed Application and Agreement, your agency affirms it will comply with all requirements of California Health and Safety Code sections 1797.5, 1797.107, 1797.190 and 1797.196 and California Code of Regulations Title 22, Division 9, Chapter 1.8, sections 100031 –100041, which include:

  • Training: A trained employee (who has passed a written and skills examination) must be available to use an AED unit during normal operating hours. Prior to placement of the AED, the appropriate number of personnel who must be certified in American Red Cross or American Heart Association CPR & AED skills will be determined.
  • Access: An unlocked, alarmed wall cabinet placed in a visible and accessible location is required. Location of wall cabinet will be determined in consultation with Sequoia Healthcare District and reasonably acceptable to both parties. By accepting an AED, HeartSafe Program participants affirm that at least annually, employees will be notified as to the location of AED units, and information describing the proper use of the AED is posted next to any installed AED.
  • Maintenance: The unit must be maintained and regularly tested according to the manufacturer’s operation and maintenance guidelines and records of such maintenance must be kept. The manufacturer’s recommendations include monthly visual battery checks for readiness and replacement of Charge Pak and electrodes every two years or in the event of a usage. The HeartSafe Program includes a reminder for these tasks, but the responsibility belongs solely to the acquiring organization.
  • Policy and Procedures: Sequoia Healthcare District will make templates available for policy and procedure implementation. Having a written plan that describes the procedures to be followed in the event of an emergency that may involve the use of an AED is required. The written plan must include immediate notification of 911, trained facility personnel at any AED deployment, in addition to reporting any use of the AED to the local EMS agency and a designated physician.

Providers who comply with these rules and all regulations governing the placement of an AED are statutorily immune from civil liability resulting from any acts or omissions in the rendering of the emergency care except for personal injury or wrongful death that result from gross negligence or willful or wanton misconduct.

Upon joining the HeartSafe program, your agency agrees as follows:

  • The agency and its agents and employees waive any and all claims they may have at any time against Sequoia Healthcare District and its agents and employees to any civil damages resulting from or connected to this program including, but not limited to, the requirements of California Health and Safety Code sections 1797.5, 1797.107, 1797.190 and 1797.196 and California Code of Regulations Title 22, Division 9, Chapter 1.8, sections 100031 -100041; the use, misuse, malfunction, installation, operation, or maintenance of AEDs; or in the training to or rendering of emergency care using AEDs (collectively “Claims”), excluding those Claims resulting from the gross negligence or willful or wanton misconduct of Sequoia Healthcare District.
  • In the event of a Claim against Sequoia Healthcare District (and its agents or employees) not resulting from the gross negligence or willful or wanton misconduct of Sequoia Healthcare District, the agency will defend and indemnify Sequoia Healthcare District from all damages (of whatever kind or nature) and defense costs (including attorneys’ fees and experts’ fees) incurred by it.
  • In any dispute arising out of or connected with this application and agreement, the prevailing party will be entitled to reimbursement of its attorneys’ fees and costs incurred.
  • The person signing below is authorized to act on behalf of the agency and to bind it to this agreement.

Agency: _____________________________________________
Signature: _____________________________________________
Title: _____________________________________________
Print Name: _____________________________________________
Date: _____________________________________________