American Heart Association Emergency Cardiovascular Care Program
Instructor Renewal Checklist
Instructions:
This checklist may be used to document successful completion of Instructor renewal requirements and contact
information. It is recommended that the Training Center keep the completed form in the Instructor's file.
Instructor Contact Information
Name:
Address/City:/State/Zip:
Instructor Card Expiraton Date :
email :
Phone #:
Other Contact Information:
Check Discipline:
HSV
BLS ACLS
PALS
Fax#:
Training Center:
Name of TC Coordinator:
Provider skills successfully demonstrated?
Provider examination completed with a score of 90% or higher?
Provider skills successfully demonstrated?
At least 4 provider courses taught in past two years or waiver obtained (see below)?
Teaching Activity:
1.
Course Name Date Location Station/Module
2.
3.
4.
5.
Instructor Update or Renewal Course:
New Instructor card issued:
Date:
Instructor update(s) attended?
Instructor Monitor Form completed and attached?
Date of Skills Exam:
Written Exam Score:
August 31, 2006
Instructor Contact Information
Instructor Renewal Information
