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Instructions:
This checklist may be used to document successful completion of Instructor/TCF renewal requirements and contact information. It is recommended that the TC keep the completed form in the instructor's file.
Instructor Contact Information
|Name: | |Instructor ID# | |
|Address: | |City: | |Zip: | |
|Home Phone: | | Work Phone: | |
|Email: | |Department: | |
|Other contact information: | |
|Discipline: HS BLS ACLS ACLS EP PALS PEARS |
|Instructor card expiration date: | | |
|Primary TC (for discipline seeking renewal): |Heartlink |
|Name of TC coordinator: |Elsie Anwah, RN, MSN |TC ID# |AL04283 |
Renewal Checklist
| Provider skills successfully demonstrated |Date: | |Method: | |
| Instructor/TCF update(s) attended |Date(s): | |
| Instructor/TCF Monitor Form completed successfully |Date: | |
| At least 4 provider courses taught in past 2 years or waiver obtained (see below) |
| If applicable (for TCF), 1 instructor/instructor renewal course taught in past two years (see below) |
Teaching Activity
|Course Name |Date |Location (TC/Site) |Station/Module |
|1. | | | |
|2. | | | |
|3. | | | |
|4. | | | |
|Instructor/Instructor Renewal Course (if renewing TCF) |
|1. | | | |
Additional courses may be attached or listed on the back of this form.
| New instructor card issued |Date: | | |
| TCF status maintained |Date: | |
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American Heart Association Emergency Cardiovascular Care Programs
Instructor/TCF Renewal Checklist
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