2004 HCP Course Roster - Texas A&M International University
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American Heart Association Emergency Cardiovascular Care Programs
ACLS for Experienced Providers (ACLS EP)
Course Roster
|Course Information | |
( Instructor Lead Instructor ___________________________________________
( Provider Lead Instructor ID_________________________________________
Lead Instructor Phone # ____________________________________
Lead Instructor Email _____________________________________
Status Renewal Date _______________________________________
Training Center Texas A&M International University____________
Training Center ID# TX-04814________________________________
Training Site Name (if applicable) _____________________________
Course Location ___________________________________________
Address __________________________________________________
City, State ZIP _____________________________________________
Course Start Date/Time _______________ Course End Date/Time _________________ Total Hours of Instruction __________
No. of Cards Issued _________ Student-Manikin Ratio __________ Issue Date of Cards ________________
|Assisting Instructors (Attach copy of instructor card for instructors aligned with a TC other than the primary TC) |
|Name and Instructor ID# Card Exp. Date |Name and Instructor ID# Card Exp. Date |
|1. |5. |
|2. |6. |
|3. |7. |
|4. |8. |
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 Lead Instructor Date
Date _________________ Course ___________________________ Lead Instructor _____________________________________
Course Participants
|Name and Email |Address/Telephone |Complete/ |Remediation/Date Completed |
|Please PRINT as you wish your name to appear on your card. Please print | |Incomplete |(if applicable) |
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