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ACLSRoster

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Bakr Alwaqfi
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15 views

ACLSRoster

Uploaded by

Bakr Alwaqfi
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Advanced Cardiovascular Life Support Course Roster

Emergency Cardiovascular Care Programs

Course Information
Lead Instructor __________________________________________
ACLS Course
Lead Instructor ID#
ACLS Update Course Card Expiration Date
HeartCode® ACLS Training Center
Training Center ID#
ACLS EP Training Site Name (if applicable)
ACLS Instructor Address
City, State ZIP
ACLS EP Instructor
Course Location

Course Start Date/Time Course End Date/Time Total Hours of Instruction

No. of Cards Issued Student-Manikin Ratio Issue Date of Cards

Assisting Instructor (Attach copy of instructor 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

KJ1216 BLS 4/16 © 2016 American Heart Association


Course Participants

Date Course Lead Instructor Lead Instr. ID#

Name and Email Remediation/Date


Complete/
Please PRINT as you wish your name to appear on your card. Please print Mailing Address/Telephone Completed
Incomplete
email address legibly. (if applicable)

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

KJ1216 BLS 4/16 © 2016 American Heart Association

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