2004 HS CPR and HCP Course Roster
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American Heart Association Emergency Cardiovascular Care Programs
Advanced Cardiovascular Life Support (ACLS)
eLearning Skills Session Roster
|Course Information | |
( HeartCode® ACLS Instructor ________________________________________________
Instructor ID#_____________________________________________ Instructor Phone__________________________________________ 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 _____________________________________________
|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 session was conducted in accordance with AHA guidelines.
____________________________________________ _______________________________________________
Signature of Instructor Date
Session Roster for ____________________________________ Instructor _____________________________________________
Course Participants (Note: If you are performing multiple skills practice and testing sessions over multiple days, you may use 1 roster.)
|Name and Email |Address |Telephone |Session Date |Session Start |Session End |Successfully |Remediation Date |
|Please PRINT as you wish your name to appear on your| | | |Time |Time |Completed |(if applicable) |
|card. Please print email address legibly. | | | | | |Y or N | |
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