American Heart Association Emergency Cardiovascular Care Programs Basic Life Support for Healthcare Providers (bls hcp) Course Roster




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American Heart Association Emergency Cardiovascular Care Programs

Basic Life Support for Healthcare Providers (BLS HCP)

Course Roster


Course Information




New Course Lead Instructor ___________________________________________

Renewal Course

Instructor Status Renewal Date ________________________________________

Provider Training Center____________________________________________

Training Center ID# ________________________________________

Training Site Name (if applicable) ____________________________

Course Location ___________________________________________

Address __________________________________________________

City, State ZIP _____________________________________________

Course Start Date/Time _______________ Course End Date/Time _________________ Total Hours of Instruction __________


No. of Cards Issued _________ Student-Manikin Ratio __________ Issue Date of Cards ________________


Assisting Instructors (Attach copy of instructor card for instructors aligned with a TC other than the primary TC)

Name and Instructor ID# Card Exp. Date

Name and Instructor ID# Card Exp. Date

1.

5.

2.

6.

3.

7.

4.

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 Date

Date _________________ Course ___________________________ Lead Instructor _____________________________________

Course Participants

Name and Email


Please PRINT as you wish your name to appear on your card. Please print email address legibly.

Address/Telephone


Complete/

Incomplete

Remediation/Date Completed

(if applicable)

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2.











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BLS HCP Course Roster, Revised March 2013


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