American Heart Association Emergency Cardiovascular Care Programs
Instructor Records Transfer Request
Instructor Records Transfer Request Revised: November 2018
Instructions: When an instructor wants to transfer to a different Training Center (TC), this form must
be completed by the instructor, the transferring TC Coordinator (TCC) and the accepting TCC. The
transferring TCC returns the completed form with the instructor’s records to the accepting TCC. The
accepting TCC contacts the instructor when the transfer is complete.
SECTION 1:
To be completed by the TCC of the accepting TC and sent or given to the transferring instructor.
Our TC is willing to accept the instructor named below as an instructor at our TC.
Instructor’s name: Instructor ID#:
We agree to keep and maintain all instructor records in accordance with our TC Agreement with the
AHA and the Program Administration Manual.
TC name: TC ID#:
TC address:
City: State: Zip code: Phone:
Signature of TCC: Date:
SECTION 2:
To be completed by the instructor who is transferring and sent or given to the transferring TCC.
I, ________________________, Instructor ID# ____________________, authorize the transfer of my
instructor records for Heartsaver
®
BLS ACLS ACLS EP PALS PEARS
®
from TC name: TC ID#:
to TC name: TC ID#:
Instructors home address:
City: State: Zip code:
Home phone: Work phone:
SECTION 3:
To be completed by the current TCC and sent with the records being transferred.
Note: All applicable instructor records, as outlined in the Program Administration Manual, must be
transferred. The transferring TC must keep copies of all transferred records for 3 years.
TC name: TC ID#:
TC address:
TC address:
City: State: Zip code: Phone:
Signature of TCC: Date:
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