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American Heart Association Emergency Cardiovascular Care Program

BLS, ACLS & PALS eLearning Skills Session Roster Course Information

BLS Programs: BLS HCP Online BLS Heartcode BLS for HCP Anytime Heartsaver Programs: Heartsaver First Aid Online Heartsaver First Aid Online w/ CPR & AED Heartsaver CPR & AED Online Heartsaver AED Anytime ACLS/PALS Programs: ACLS Heartcode PALS Heartcode Course Start Date/Time_______________ # of Cards to be Issued_________ Name Lead Instructor ___________________________________________ Status: BLS Instructor BLS TCF/RF Instructor Renewal Date: ____________________________________ Course Location: __________________________________________ Course Address: __________________________________________ ___________________________________________ Site Number (if applicable): __________________ Total hours of Instruction __________ Issue Date of cards________________ Instr. card Exp. Date

Course End Date/Time_________________ Student/Manikin Ratio__________ Instr. card Exp. Date Name

Assisting Instructors / Specialty Faculty (Attach copy of instructor card for instructors aligned with other than primary TC) 1. 2.

____________________________________________

3. 4. _______________________________________________

Date

OFFICE USE ONLY

I verify that this information is accurate and truthful, and that it may be confirmed. This course was taught in accordance with AHA guidelines. Signature of Course Director

Provider Cards picked up from Tulane Sim Center CTC. Provider Cards issued from Training Site stock. Provider Cards to be mailed to address below. Enclosed is payment of $___________. Mailing address: _______________________________________________________

Payment Received Order Fulfilled Entered into WorldPoint

Skills Session Roster 2006, page 1

DATE_________________

COURSE ___________________ LEAD INSTRUCTOR ______________________________________

** YOU MUST INCLUDE COPIES OF EACH STUDENTS' PART 1 COMPLETION CERTIFICATE WITH THIS ROSTER ** Course Participants

NAME Please PRINT as you wish your name to appear on your card. Address Telephone Complete/ Incomplete Remediation/ Date Completed

1. 2. 3. 4. 5. 6. 7. 8. 9. 10.

Skills Session Roster 2006, page 2

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Microsoft Word - Skills Session Roster.docx

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