ACTIVITY REPORT FORM
ACTIVITY REPORT FORM
Instructions:
Please complete an Activity Report every six months only if you have not/can not enter your classes online. The report of your class numbers and type of course is included in a report by our training center which summarizes the activity of all of our instructors and presented to the American Heart Association every January 1st and July 1st .
The report of your classes taught is a requirement by the American Heart Association to retain your Instructor Certification.
Please contact our office for assistance in reporting your classes.
Phone: 651-632-5032
Thank you!
ACTIVITY REPORT FORM
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Fire/EMS/Safety Center – Multi-Regional Training Center
30 7th St.E., Suite 350, St. Paul, MN 55101-7804
Toll Free- 800-311-3143 Office - 651-632-5032 Fax- 651-649-5409
Reporting Period: _____January 1 - June 30, _____ July 1 - December 30,
Name: _____________________________________ MRTC # __________
Address: ______________________________________________________ City/State/Zip:______________________
Telephone: Home: ________________________Email:___________________
Work: ________________________ Email: ___________________
Level of Certification:
________ Instructor ________MRTC Faculty ________ Regional Faculty
Type of Certification:
________ BLS _________ ACLS _________ PALS
MRTC
Date: Course Taught: # Students: Assisting Instructors:
w/ MRTC#
___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Date: Course Taught: # Students MRTC Asst.Instructors
& their MRTC#
_________________________________________________________________________
_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Call for questions:
Gayle Steiner,
Gayle.Steiner@so.mnscu.edu
651-649-5944
Gayle.
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