Advanced Cardiovascular Life Support Course Roster
Emergency Cardiovascular Care Programs
Course Information
ACLS Course
ACLS Update Course
HeartCode
®
ACLS
ACLS EP
ACLS Instructor
ACLS EP Instructor
Lead Instructor __________________________________________
Lead Instructor ID#
Card Expiration Date
Training Center
Training Center ID#
Training Site Name (if applicable)
Address
City, State ZIP
Course Location
Course Start Date/Time
No. of Cards Issued
Course End Date/Time
Student-Manikin Ratio
Total Hours of Instruction
Issue Date of Cards
Assisting Instructor (Attach copy of instructor 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 conrmed. This course was taught in accordance with AHA guidelines.
Signature of Lead Instructor Date
KJ1216 BLS 4/16 © 2016 American Heart Association
KJ1216 BLS 4/16 © 2016 American Heart Association
Name and Email
Please PRINT as you wish your name to appear on your card. Please print
email address legibly.
Mailing Address/Telephone
Complete/
Incomplete
Remediation/Date
Completed
(if applicable)
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Course Participants
Date Course Lead Instructor Lead Instr. ID#