Lapsed Instructor form | APR/2021 | Version 1
1
Lapsed Instructor Form
Personal details
Surname First name
Title Job Role
Registration type Registration no.
Email/LMS Username
Instructor Potential course details
Provider course type ALS NLS ARNI EPALS ILS/PILS Other
Course date
Course Centre
Course Centre (IC 1)
Course Centre (IC 2)
Instructor course details
Instructor course type ALS NLS ARNI EPALS ILS/PILS Other
Date last taught
Course Centre
Recent teaching experience
Are you an Instructor or IC for any other course (e.g. APLS, ATLS)? If yes please complete details below
Course type Course type
Date you qualified as
an Instructor
Date you qualified as
an instructor
Date you last taught on
this course
Date you last taught
on this course
Reasons for delay in completing training/fulfilling instructor teaching requirements
FOR RCUK USE ONLY
Coordinator recommendation
Courses Manager