Course Roster - Roswell



Course Roster Healthcare Provider Only

( on-line Renewal

1. Type of Course

θ BLS Health Care Provider θ New θ Renewal

θ ACLS Provider θ New θ Renewal

θ ACLS-EP Provider θ New θRenewal

θ PEARS θ New θRenewal

θ PALS Provider θ New θ Renewal

2. Course Begin Date: ____ Time:__ ___________

3. Course End Date: ______________ Time:____________

4. Number of Students: _________________

5. Number Completed: __________________

6. Site Location:

Site complete Address:________________________________

7. Lead Instructor: _____ _________________ Number__________________________

1. Medical/Course Director:___________________________________

(If different from lead instructor)

9. Assisting Instructors

| | |

|Name of Assisting Instructor(s) and Number |Name of Assisting Instructor(s |

| |and Number |

|1. | |

| |6 |

|2 | |

| |7 |

| | |

|3 |8 |

| | |

|4 |9 |

| | |

|5 |10 |

1. Comments: (Use additional pages if necessary) _____________________________________________________________________________________________________________________________________________________________________________________________________________

1. Fees:

BLS Provider

_____________________ X $6.00 = $_________________

(Number of students) (Total Fees)

ACLS and PALS

_____________________ X $21.00 = $_________________

(Number of students) (Total Fees)

12. Equipment Numbers : _____________________________

12-a Equipment cleaned by: ____________________________

1. Method of Payment: Check or MO: #_________________

PO#______________________(Attached PO)

Credit Card: CC#_______________________V-Code______

Type of card_____________ Expiration date:__________

Name on card____________________________________

1. Evaluation completed and included:__________

1. Classes schedule included (ACLS and PALS only): __________

If you are lead instuctor it is not necessary to list yourself as assistant instructor. Non ENMU-R, CTC Instructor

Please Attach Copy of card.

Rosters received 10 days after the course will have a late roster fee of $10.00 for every 10 days late.

This excludes Training Sites.

Participant List (PLEASE PRINT CLEARLY-MUST BE COMPLETE)

| | | | | | |Remediation |

|First Name, Middle, Last Name, |Address |Written Score |Pass all Skill|Course |Instructor | |

| |City/State/Zip | |and Cases* |Completion |Potential+ | |

| | | |Yes/No |Yes/No** |Yes/No | |

| | | | | | | |

| | | | | | | | |

|1 | | | | | | | |

| | | | | | | | |

|2 | | | | | | | |

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|3 | | | | | | | |

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|4 | | | | | | | |

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|5 | | | | | | | |

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|6 | | | | | | | |

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|7 | | | | | | | |

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|8 | | | | | | | |

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|9 | | | | | | | |

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|10 | | | | | | | |

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|11 | | | | | | | |

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|12 | | | | | | | |

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|13 | | | | | | | |

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|14 | | | | | | | |

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|15 | | | | | | | |

| | | | | | | | |

|16 | | | | | | | |

* Cases for ACLS and PALS Only. **If the student does not complete the course, the reason(s) must be noted and attached, Please attach written evaluation and documented remediation steps taken to remediate the student. + To make Instructor Potential, the student must have a 92% (initial attempt) on written exam, outstanding performance in all station, recommendation from the lead instructor and a willingness to teach.

I verify that this information is accurate and truthful, and that it may be verified. This course was taught in accord with the guidelines of the American Heart Association.

Signature of Instructor ____________________________________________ Date: _____________________________________

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