Lifesaver Recognition
Please complete this brief form so we can recognize you or your colleague for saving a life!
Sign in to Google to save your progress. Learn more
Email *
Name of individual completing this
Your NATA Number *
Your NPI Number *
Name of member who saved a life (including credentials)
Affiliation
Email of the member who saved a life
Date of event
MM
/
DD
/
YYYY
Brief description of the life-saving event.  To remain in compliance with HIPAA, please avoid sharing any personal health information.  (Example: "Performed CPR/AED on a basketball player.  We maintained basic life support until the paramedics arrived.")
A copy of your responses will be emailed to the address you provided.
Submit
Clear form
Never submit passwords through Google Forms.
reCAPTCHA
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy