UNMC AHA Training Center EMS/Trauma Programs – AHA Roster Face Page
Date
Length-(hrs/min)
Ratio
Start Time End Time
Location
TS
Course Information- place an X in the corresponding boxes
ACLS PALS HCP
Initial Renewal
Provider Instructor
CORE CONTENT
OPTIONAL CONTENT
HS CPR/AED
Child CPR/AED Infant CPR
Skills Only Printed Online Cert
Total # Students
CORE CONTENT
HS FA
CPR In the Schools
OPTIONAL CONTENT
Adult CPR/AED Child CPR/AED Infant CPR
ECG & Pharm
F&F Adult F&F Child F&F Infant
Equipment Cleaned by
A/W Management
Medical Director
Dr. Jeff Harrison
PEARS
HS BBP
TCC & RF
Deb Von Seggern-Johnson
Off –site only: Address/Name Cards should be mailed to
Course Instructor Information
Lead Instructor/Course Director
AHA ID #
Card Exp.
Station taught or Include Agenda
Instructor(s)
Roster Policy
Only completed paperwork submitted will be honored by UNMC when submitted in a timely manner.
PLEASE remember to fill out all information & legibly – we need to be able to read it and not guess.
All paperwork must be submitted to UNMC with 10 days of holding the course.
UNMC MUST be notified prior to holding any course.
Current cards are required for Renewal courses. Copies of cards must be submitted with course paperwork
when an off-site course is being conducted.
Current BLS card are required for ACLS/PALS–Card will be held 30 days until proof of BLS is provided.
Current HCP or ACLS or PALS Expiration Date – Required for Renewal courses.
Office Use Only
CIK # ________________
Date Rec’d _____________________
Created 1/2013 by ddvsj
Date Cards Mailed __________________