ACLS PALS Instructor Roster 2013 - Ochsner.org

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Date cards mailed: N/A
Ochsner Health System
Community Training Center
1201 South Clearview Parkway, Suite 500
Building B – 5 th Floor
New Orleans, LA 70121
Voice: 504-842-6684 Fax: 504-842-9976
American Heart Association Emergency Cardiovascular Care Program
ACLS/PALS Instructor Course
Course Roster Form
Course Information
❏ New Course ❏ Renewal Course Course Director:
Status: ❏ BLS TC Faculty ❏ BLS Regional Faculty
❏ ACLS Instructor: Status Renewal Date: __________________ Instructor ID#_________________
This course includes all of the ACLS Instructor Course core components.
Training Center: OCHSNER COMMUNITY TRAINING CENTER_
❏ PALS Instructor: Site Name:
This course includes all of the PALS Instructor Course core components.
Course Location:
Address:
City, State, Zip:
Course Start Date: ________________ Course End Date: ___________________ Total Hours of Instruction: ____________________
Course Start Time: ______________ Course End Time: ___________________ Student/Manikin Ratio: _______________________
Assisting Instructors / Specialty Faculty (Attach copy of instructor card for instructors aligned with other than 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 Course Director Date
1
Revised 06/14/13
Course Roster

DATE_________________ COURSE ACLS/PALS Instructor
INSTRUCTOR ______________________________________
Course Participants
NAME
Please PRINT as you wish your name to
appear on your card.
Address Telephone Complete/Incomplete Date Remediated
1.
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Revised 06/14/13
Course Roster