Basic Life Support Course Roster Emergency Cardiovascular ...
Basic Life Support Course Roster
Emergency Cardiovascular Care Programs
Course Information
BLS Course (instructor-led) HeartCode? BLS BLS Instructor
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 Instructor
Name and Instructor ID# 1. 2. 3. 4.
(Attach copy of instructor aligned with a TC other than the primary TC)
Card Exp. Date
Name and Instructor ID#
Card Exp. Date
5.
6.
7.
8.
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
KJ1216 BLS 4/16 ? 2016 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.
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
KJ1216 BLS 4/16 ? 2016 American Heart Association
Lead Instructor Mailing Address/Telephone
Lead Instr. ID#
Complete/ Incomplete
Remediation/Date Completed (if applicable)
................
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