Life Support Course Roster Form PDF Details

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.

QuestionAnswer
Form NameLife Support Course Roster Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namescardiovascular life pediatric, support pediatric roster, basic life supporta course roster, advanced cardiovascular life support course roster

Form Preview Example

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

 

Course Director___________________________________________

 

 

 

Status:

Instructor/CD

TC Faculty

Regional Faculty

ACLS

 

 

Lead Instructor ___________________________________________

ACLS Provider

ACLS EP Provider

Status:

Instructor/CD

TC Faculty

Regional Faculty

 

 

 

Training Center____________________________________________

PALS

 

 

Site Name________________________________________________

PALS Provider

 

 

 

 

 

 

 

 

 

 

Course Location___________________________________________

Physician Instructor:

 

 

 

 

 

 

 

 

 

 

Address _________________________________________________

________________________________________________________

 

 

 

 

 

 

 

 

City, State ZIP ___________________________________________

 

 

 

Course Start Date/Time_______________

Course End Date/Time_________________

Total hours of Instruction __________

# of Cards Issued_________

Student/Instructor Ratio__________

 

Issue Date of cards________________

 

 

 

 

 

 

 

 

Assisting Instructors / Specialty Faculty (Attach copy of instructor card for instructors aligned with other than primary TC)

Name

Instr. card Exp. Date

Module / Station

Name

Instr. card Exp. Date

Module / Station

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 Course Director

Date

 

ALS Course Roster Revised March 2004, page 1

DATE_________________ COURSE ______________________________ COURSE DIR. __________________________________

Course Participants

NAME

 

 

Complete/

Remediation/

Exam

 

Please PRINT as you wish your name to

Address

Telephone

Date

 

Incomplete

Score

 

appear on your card.

 

 

Completed

 

 

 

 

 

 

 

 

 

 

 

 

 

1.

 

 

 

 

 

 

 

 

 

 

 

 

 

2.

 

 

 

 

 

 

 

 

 

 

 

 

 

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8.

 

 

 

 

 

 

 

 

 

 

 

 

 

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10.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ALS Course Roster Revised March 2004, page 2