The Life Support Course Roster form, created by the American Heart Association for its Emergency Cardiovascular Care Program, serves as a comprehensive document for organizing and recording key details of Advanced Cardiovascular Life Support and Pediatric Advanced Life Support courses. This essential tool not only facilitates the registration of new and renewal courses but also allows course directors and instructors to officially log participant engagement, including overall performance and certification issuance. Covering course information such as directorship, instructor details, training center, site name, and course location, the form ensures that all logistical aspects are meticulously accounted for. Furthermore, it documents the course timeline, total instructional hours, the student-to-instructor ratio, and the details regarding the issuance of completion cards. The roster requires the inclusion of assisting instructors or specialty faculty, necessitating a copy of the instructor card for those aligned with training centers other than the primary one specified. This level of detail underscores the form's role in maintaining the integrity and quality of life support training, adhering strictly to AHA guidelines to certify participants efficiently and accurately. Signatures from the course director affirm the veracity of the information provided, highlighting the form's importance in the administrative process of emergency cardiovascular care education.
Question | Answer |
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Form Name | Life Support Course Roster Form |
Form Length | 2 pages |
Fillable? | No |
Fillable fields | 0 |
Avg. time to fill out | 30 sec |
Other names | cardiovascular life pediatric, support pediatric roster, basic life supporta course roster, advanced cardiovascular life support course roster |
American Heart Association Emergency Cardiovascular Care Program
Advanced Cardiovascular Life Support and Pediatric Advanced Life Support
Course Roster Form
Course Information
New Course |
Renewal Course |
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Course Director___________________________________________ |
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Instructor/CD |
TC Faculty |
Regional Faculty |
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ACLS |
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Lead Instructor ___________________________________________ |
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ACLS Provider |
ACLS EP Provider |
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Instructor/CD |
TC Faculty |
Regional Faculty |
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Training Center____________________________________________ |
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PALS |
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Site Name________________________________________________ |
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PALS Provider |
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Course Location___________________________________________ |
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Physician Instructor: |
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Address _________________________________________________ |
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City, State ZIP ___________________________________________ |
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Course Start Date/Time_______________ |
Course End Date/Time_________________ |
Total hours of Instruction __________ |
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# of Cards Issued_________ |
Student/Instructor Ratio__________ |
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Issue Date of cards________________ |
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Assisting Instructors / Specialty Faculty (Attach copy of instructor card for instructors aligned with other than primary TC)
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Instr. card Exp. Date |
Module / Station |
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Instr. card Exp. Date |
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I verify that this information is accurate and truthful, and that it may be confirmed. This course was taught in accordance with AHA guidelines.
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Signature of Course Director |
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ALS Course Roster Revised March 2004, page 1 |
DATE_________________ COURSE ______________________________ COURSE DIR. __________________________________
Course Participants
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Complete/ |
Remediation/ |
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Please PRINT as you wish your name to |
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Incomplete |
Score |
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appear on your card. |
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Completed |
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ALS Course Roster Revised March 2004, page 2 |