2016-2017 MI HEARTSafe School Application
Welcome to the MI HEARTSafe School award application. Your submission will be saved and submitted upon completion of all nine sections. Please use navigation arrows within application. Please indicate e-mail address below to receive confirmation of application.
Email address *
Introduction
** Application must be received by May 15, 2017 for consideration for the 2016/2017 school year. Schools are strongly encouraged to submit applications using online system. An alternative hard copy is available at https://www.migrc.org/Resources/ViewResource.aspx?rid=1302. **

The Michigan Department of Health and Human Services (MDHHS), Michigan Department of Education (MDE), Michigan High School Athletic Association (MHSAA) and American Heart Association (AHA) in conjunction with the Michigan Alliance for Prevention of Sudden Cardiac Death of the Young (MAP-SCDY) have developed an initiative to award Michigan schools with a MI HEARTSafe School designation. The MI HEARTSafe School program encourages schools to prepare and protect students, staff, and visitors in the event of a cardiac emergency.

The MI HEARTSafe School designation is awarded when a school has completed all of the following criteria:

1. A written cardiac emergency response plan reviewed at least annually with staff as designated by state law for during the school day AND for organized after-school activities and sports if applicable (HB4713 approved in February 2014).

2. A cardiac emergency response team with current CPR/AED certification, sufficient to respond to an emergency during school hours AND during organized after-school activities and sports if applicable.

3. At least 10% of staff, 50% of coaches including 100% head coaches of varsity sports, and 100% of P.E. staff with current CPR/AED certification.

4. A sufficient number of accessible, properly maintained and inspected AEDs ready to use, with signs identifying AED locations.

5. The performance of at least one cardiac emergency response drill per year prior to May 15, 2017.

6. All athletic pre-participation screening completed with the Michigan High School Athletic Association (MHSAA) form (updated in 2016).

For further information on how to become a MI HEARTSafe School, please visit www.migrc.org/miheartsafe to review the MI HEARTSafe School Program Questions and Answers document. If you have additional questions, please contact:

Debra Duquette, MS, CGC
MDHHS Genomics Program Coordinator
E-mail: duquetted@michigan.gov
Phone: 517.335.8286 Fax: 517.335.9790

An e-mail confirmation will be sent to you after submitting the application.
Please contact Debra Duquette, MS, CGC by phone if you do not receive this confirmation.

Name and Address of School Building Seeking Designation:
* Please complete an application for each school building that would like to receive the MI HEARTSafe School designation. OPTIONAL exploratory questions that are not part of the award criteria are also included. These optional questions are currently not a requirement of the MI HEARTSafe School designation.
Name of School Building *
Your answer
Name of School District *
Your answer
Address of School Building *
Your answer
County of School Building *
Your answer
Zip Code of School Building *
Your answer
Does this school building have organized after-school activities and sports? *
Does this school participate in organized sports? *
Has this school been previously awarded as a MI HEARTSafe school? *
School Principal: *
Your answer
Phone: *
Your answer
E-mail: *
Your answer
Who should we contact with any questions concerning your applications (please list an alternate contact than the principal)?
Contact: *
Your answer
Position: *
Your answer
Phone: *
Your answer
E-mail: *
Your answer
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