DATE: NAME:



|DATE: | |NAME: | |

|DEPT BILLING CODE#: | |DEPT NAME: | |

|CHILDREN’S EMPLOYEE #: | |EDUCATOR (if N/A then Supervisor): | |

|CHILDREN’S E-MAIL (to email Student Study Guide): | |

|HOME PHONE: | |WORK PHONE: | |

|PROFESSION (Job Title): | |

|PROVIDER CARD EXPIRATION Month / Year: | |

|Non COA EMPLOYEE- PLACE OF EMPLOYMENT: | |

|Non COA EMPLOYEE must pay $55 to Nursing Education before HeartCode is assigned |

|COURSE TITLE: HeartCode BLS Part 1 (Module will be assigned in Children’s University/HealthStream) |

| |

|Circle/mark date and session time (below) to indicate the Skills Validation session you would like to attend |

|Skills Check Off dates: Jan 4, Feb 15, Apr 5, May 3, Jul 12, Aug 16, Oct 25, Nov 21 (Tuesday) |

|Skills session times: depending on availability. So mark 1st , 2nd and 3rd choice |

|__ 0730 __ 0800 __ 0830 __ 0900 __ 0930 __ 1000 __ 1300 __ 1330 __ 1400 __ 1430 __ 1500 |

Complete this form and return it to Nursing Education as soon as possible.

An email confirmation will be sent

COA EMPLOYEES: HeartCode BLS Hands On skills validation assignment will be appear on Children’s University on your VIEW TRANSCRIPT 30 days prior to skills session. The Online module will appear next day after 0800.

Non COA EMPLOYEES: HeartCode BLS Online will be assigned to you in COA’s HealthStream.

An email confirmation will be sent.

HeartCode BLS On Line Completion Certificate must be presented at Hands On Skill Validation.

Revised 9/20/12, 11/2012, 10/2013, 10/2016

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2017

The Surpora Thomas Pediatric Nursing Education and Research Center

Children’s of Alabama

1600 7th Ave South / Harbor Bldg/Ste 410

Birmingham, AL 35233 Office: 205-638-9127

Fax: 205-638-6066 Email: Nursing.Education@

BASIC LIFE SUPPORT for HEALTHCARE PROVIDERS

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