BLS Roster 2013 - Ochsner.org

For CTC use only:
Payment type: ______________
Date cards mailed: ___________
Issued at Site: ________
Ochsner Health System
OCHSNER COMMUNITY TRAINING CENTER
1201 South Clearview Parkway, Suite 500
Building B - 5 th Floor
New Orleans, Louisiana 70121
Office 504-842-6684 Fax 504-842-9976
American Heart Association Emergency Cardiovascular Care Programs
Basic Life Support for Healthcare Providers (BLS HCP) Course Roster
Course Information
❏ New Course Lead Instructor_________________________________________________
❏ Renewal Course Status Renewal Date _______________ Instructor ID#__________________
Training Center Ochsner Community Training Center ID# LA 5334
Training Site Name (if applicable) ___________________________________
Course Location ________________________________________________
Address ________________________________________________________
City, State ZIP __________________________________________________
Mail Cards to: ___________________________________________________
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
(Attach copy of instructor card for instructors 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
BLS HCP Course Roster 2013, page 1

Date: ______________________Course:____________________________________ Course Director: __________________________
Course Participants
NAME
Please PRINT as you wish your name to appear
on your card.
1.
Address
Telephone
Complete/
Incomplete
Remediation/
Date Completed
Exam
Score
2.
3.
4.
5.
6.
7.
8.
9.
10.
BLS HCP Course Roster 2013, page 2