Basic Life Support Course Roster - American Heart Association
[Pages:2]Basic Life Support Course Roster
Emergency Cardiovascular Care Programs
Course Information
BLS Course BLS Renewal Course HeartCode? BLS BLS Instructor Course
Lead Instructor Lead Instructor ID# Card Expiration Date Training Center Training Center ID# Training Site Name (if applicable) Address City, State ZIP Course Location
Course Start Date/Time No. of Cards Issued
Course End Date/Time Student-Manikin Ratio
Total Hours of Instruction Issue Date of Cards
Assisting Instructors
Name and Instructor ID# 1. 2. 3. 4.
Card Exp. Date
Name and Instructor ID# 5. 6. 7. 8.
Card Exp. Date
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
KJ-1216 BLS R4/21 ? 2021 American Heart Association
Date
Course Participants
Date
Course
Name and Email
Please PRINT as you wish your name to appear on your card. Please print email address legibly.
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KJ-1216 BLS R4/21 ? 2021 American Heart Association
Lead Instructor Mailing Address/Telephone
Lead Instr. ID#
Complete/ Incomplete
Remediation/Date Completed (if applicable)
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