Edcor BLS FirstAide Roster



TCF/Instructor Information:Name:Phone:Email: Training Location:Training Site: Address: City: State: Zip:Type of Program:Program Date(s):HEARTSAVER (Please check all that apply to class)HEARTSAVER PEDIATRIC (Please check all that apply to class)HEALTH CARE PROVIDER OTHER First AidCPR/AEDChild CPR/AEDInfant CPRWritten TestFirst Aid Skills Check offCPR Skills Check off FA/CPR/AED Skills CheckoffFirst AidCPR/AEDAdult CPR/AEDInfant CPRWritten TestAsthma Care VideoFirst Aid/CPR/AED Skills Check off BLSBLS skills checkoffBLS InstructorHeartsaver InstructorHeartsaver Bloodborne Pathogens CPR for SchoolsFriends and FamilyThe course for which you are enrolled may include physical strain, possibility for cross infection, and emotional stress. CPR is very strenuous both in practicing on the manikin and performing CPR on a cardiac arrest victim. If you have any medical conditions or cardiovascular disease history that may be aggravated by this course, please consult your physician as to whether you should participate in a CPR course. If you have any reservations about your ability to perform CPR on a cardiac arrest victim, you may want to reconsider taking this course. If you have recently had any infectious disease, including upper respiratory infection or open sores on your mouth and/or on hands, it is imperative to defer manikin practice. The AHA and its TCs are not certifying agencies. The AHA and its TCs are not responsible for the level of classes taught to participants.By filling in my name by hand, initialing by my typed name below I have acknowledged that I have read all the above statements and absolve the American Heart Association, its TCs, and instructors from any liability associated herewith. I do not currently have any infectious disease.InitialName AddressEmailExam ScoreStatusRemediation/ Date Completed1CompletedCompleted after remediationNot yet completed2CompletedCompleted after remediationNot yet completed3CompletedCompleted after remediationNot yet completed4CompletedCompleted after remediationNot yet completed5CompletedCompleted after remediationNot yet completed6CompletedCompleted after remediationNot yet completed7CompletedCompleted after remediationNot yet completedBy filling in my name by hand, initialing by my typed name below I have acknowledged that I have read all the above statements and absolve the American Heart Association, its TCs, and instructors from any liability associated herewith. I do not currently have any infectious disease.8CompletedCompleted after remediationNot yet completed9CompletedCompleted after remediationNot yet completed10CompletedCompleted after remediationNot yet completed11CompletedCompleted after remediationNot yet completed12CompletedCompleted after remediationNot yet completed13CompletedCompleted after remediationNot yet completed14CompletedCompleted after remediationNot yet completed15CompletedCompleted after remediationNot yet completed16CompletedCompleted after remediationNot yet completedThe American Heart Association strongly promotes knowledge and proficiency in BLS, ACLS, PEARS, and PALS and has developed instructional materials for this purpose. Use of these materials in an educational course does not represent course sponsorship by the American Heart Association Any fees charged for such a course, except for a portion of fees needed for AHA course material, do not represent income to the pleted Course Roster must be submitted to EdCor within 14 days of the class. For Students who have not yet met course completion requirements, a copy of their written examination answer sheet and skills performance sheet is attached to the roster. For online courses copy of the on-line certificate CPR Critical Skills Testing Check List for BLS Provider must be available by the Training Site or Instructor upon request at any time or sent to EdCor within 30 days of the course. I,__________________________________, verify that I have followed the AHA requirements in presentation and testing for this class and have used the AHA (Course Director Signature)course materials. I have included the roster, evaluations or summary of evaluations, and required written test answer sheet and skills performance sheet for any student that has not yet met AHA completion requirements for the Training Site and Training Center files.Date: (Valid Signature is accepted when full name is typed in above)Additional Instructors for this course: By filling in my name by hand, initialing by my typed name below I have acknowledged that I have read all the above statements and absolve the American Heart Association, its TCs, and instructors from any liability associated herewith. I do not currently have any infectious disease.InitialNameAddressEmailExam ScoreStatusRemediation/ Date Completed17CompletedCompleted after remediationNot yet completed18CompletedCompleted after remediationNot yet completed19CompletedCompleted after remediationNot yet completed20CompletedCompleted after remediationNot yet completed21CompletedCompleted after remediationNot yet completed22CompletedCompleted after remediationNot yet completed23CompletedCompleted after remediationNot yet completed24CompletedCompleted after remediationNot yet completed ................
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