National HeartSmart Institute

Please use this form to request specialized classes, or to contact us to get more information about
our company, products, or services.

Please fill in the appropriate information if applicable.

Please indicate the month you would be interested in us teaching for you:

If you have already worked with us in the past, please provide your user name (customer number).
This information will help to expedite your request to better serve you.

Thank you for taking the time to answer the questions in our survey.

Request More Information

SECTION A -- Corporate Information

What is the name of your organization?

How many employees at your organization?

Type of business performed:

SECTION B -- Areas of interest

Please check all that apply:

Forklift Operator Safety

Advanced Cardiac Life Support

Hand and Power Tool Safety

Automated External defibrillator operation

Babysitters Training

Hazard Communication

Healthcare Provider BLS

Basic First Aid

Blood Born Pathogens

Healthy Heart Matters

Lockout/Tagout

Cardiopulmonary Resuscitation (CPR)

Chains, Slings, and Hoist Safety

Machine Guard/Conveyor Safety

Confined Space Entry

Machine Shop Safety

Prevention of Slips, Trips, And Falls

Employee Safety Orientation

Ergonomics

Safe Lifting/Back Injury Prevention

Fire Extinguisher Use and Safety

Stress Management

Wilderness First Aid

Fire Prevention and Safety

First Responder Training

Workplace Violence Awareness

SECTION C -- Address Information

Your Name:

Your E-Mail Address:

Your Phone Number:

Comments: