Form KJ-1216 BLS at a glance
What it is: Basic Life Support Course Roster, Emergency Cardiovascular Care Programs, KJ-1216 BLS R10/20, American Heart Association.
Who signs: Signature of Lead Instructor Date.
A filled-in Form KJ-1216 BLS example: a lead instructor lists a class
How to fill out Form KJ-1216 BLS, box by box
BLS Course
BLS Course, BLS Renewal Course, HeartCode® BLS, BLS Instructor Course.
Lead Instructor and Training Center
Enter the Lead Instructor, the Lead Instructor ID# and the Card Expiration Date.
Enter the Training Center, the Training Center ID# and the Training Site Name (if applicable).
Address and Course Location
Enter the Address, the City, State ZIP and the Course Location.
Course dates, hours and cards
Enter the Course Start Date/Time, the Course End Date/Time and the Total Hours of Instruction.
Enter the No. of Cards Issued, the Student-Manikin Ratio and the Issue Date of Cards.
Assisting Instructors
Under Assisting Instructors, enter the Name and Instructor ID# and the Card Exp. Date.
Signature of Lead Instructor
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.
Name and Email
Enter the Date, the Course, the Lead Instructor and the Lead Instr. ID#.
Under Name and Email, please PRINT as you wish your name to appear on your card. Please print email address legibly.
Enter the Mailing Address/Telephone, Complete/ Incomplete and Remediation/Date Completed (if applicable).
Sources
[1] Basic Life Support Course Roster (KJ-1216 BLS R10/20), American Heart Association (the Official source link on this page).
