Ochsner Health System ACLS/PALS Instructor Course ... - Ochsner.org
Ochsner Health System ACLS/PALS Instructor Course ... - Ochsner.org
Ochsner Health System ACLS/PALS Instructor Course ... - Ochsner.org
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For CTC use only:<br />
Payment type: N/A<br />
Date cards mailed: N/A<br />
<strong>Ochsner</strong> <strong>Health</strong> <strong>System</strong><br />
Community Training Center<br />
1201 South Clearview Parkway, Suite 500<br />
Building B – 5 th Floor<br />
New Orleans, LA 70121<br />
Voice: 504-842-6684 Fax: 504-842-9976<br />
American Heart Association Emergency Cardiovascular Care Program<br />
<strong>ACLS</strong>/<strong>PALS</strong> <strong>Instructor</strong> <strong>Course</strong><br />
<strong>Course</strong> Roster Form<br />
<strong>Course</strong> Information<br />
❏ New <strong>Course</strong> ❏ Renewal <strong>Course</strong> <strong>Course</strong> Director:<br />
Status: ❏ BLS TC Faculty ❏ BLS Regional Faculty<br />
❏ <strong>ACLS</strong> <strong>Instructor</strong>: Status Renewal Date: __________________ <strong>Instructor</strong> ID#_________________<br />
This course includes all of the <strong>ACLS</strong> <strong>Instructor</strong> <strong>Course</strong> core components.<br />
Training Center: OCHSNER COMMUNITY TRAINING CENTER_<br />
❏ <strong>PALS</strong> <strong>Instructor</strong>: Site Name:<br />
This course includes all of the <strong>PALS</strong> <strong>Instructor</strong> <strong>Course</strong> core components.<br />
<strong>Course</strong> Location:<br />
Address:<br />
City, State, Zip:<br />
<strong>Course</strong> Start Date: ________________ <strong>Course</strong> End Date: ___________________ Total Hours of Instruction: ____________________<br />
<strong>Course</strong> Start Time: ______________ <strong>Course</strong> End Time: ___________________ Student/Manikin Ratio: _______________________<br />
Assisting <strong>Instructor</strong>s / Specialty Faculty (Attach copy of instructor card for instructors aligned with other than primary TC)<br />
Name and <strong>Instructor</strong> ID# Card Exp. Date Name and <strong>Instructor</strong> ID# Card Exp. Date<br />
1. 5.<br />
2. 6.<br />
3. 7.<br />
4. 8.<br />
I verify that this information is accurate and truthful, and that it may be confirmed. This course was taught in accordance with AHA guidelines.<br />
____________________________________________ _______________________________________________<br />
Signature of <strong>Course</strong> Director Date<br />
1<br />
Revised 06/13/11<br />
<strong>Course</strong> Roster
DATE_________________ COURSE <strong>ACLS</strong>/<strong>PALS</strong> <strong>Instructor</strong><br />
INSTRUCTOR ______________________________________<br />
<strong>Course</strong> Participants<br />
NAME<br />
Please PRINT as you wish your name to<br />
appear on your card.<br />
Address Telephone Complete/Incomplete Date Remediated<br />
1.<br />
2.<br />
3.<br />
4.<br />
5.<br />
6.<br />
7.<br />
8.<br />
9.<br />
10.<br />
2<br />
Revised 06/13/11<br />
<strong>Course</strong> Roster