COURSE SUMMARY – BASIC COURSES



|[pic] |American Heart Association Emergency Cardiovascular Care Program |

| | |

| |Roster Form- BASIC LIFE SUPPORT COURSES |

| BLS Provider | Heartsaver CPR AED: Opt Modules- Child Infant |Online Skills Testing |

| |Heartsaver First Aid |HeartCode BLS |

|BLS Renewal |Heartsaver First Aid CPR AED: Opt Modules- Child Infant |Heartsaver CPR AED |

| |Heartsaver Pediatric First Aid CPR AED: Opt Modules- Adult Asthma |Heartsaver First Aid |

|Family and Friends CPR |Heartsaver Bloodborne Pathogens |Heartsaver First Aid CPR AED |

| | |Heartsaver Pediatric First Aid |

| | |CPR AED |

| | |# Adult Manikins: _____________ |

|Course Start Date/Time: __ _______________________ __ |Site: ____________________________ _____________ |# Child Manikins: _____________ |

| | |# Baby Manikins: _____________ |

|Course End Date/Time: _____________________________ |City: _________________________________________ |# AEDs: ____________________ |

| | |# Participants: _______________ |

|Total Hours of Instruction: ___________________________ |Student/Manikin Ratio: ___________________________ |# of Cards Issued: ____________ |

|Instructor Information: (Attach copy of instructor card for instructors aligned with TCs other than UnityPoint Health CTC) |

| |Instructor Name |Instr. Card Exp. Date |Module/Stations taught |

|Lead | | | |

|Assisting | | | |

|Assisting | | | |

|Assisting | | | |

|Assisting | | | |

|Assisting | | | |

|Assisting | | | |

|Assisting | | | |

|Assisting | | | |

I verify that this information is accurate and truthful, and that it may be confirmed. This course was taught in accordance with AHA guidelines. The manikins were decontaminated appropriately following this course.

_____________________________________________________________ ____________________

Signature of the Lead Instructor Date

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