American Heart Association Emergency Cardiovascular Care Program
Heartsaver CPR AED
Course Roster Form
Course Information
Heartsaver CPR AED Provider Course:
This course included the Heartsaver Core components:
† Adult CPR/AED
† Child CPR/AED (optional)
† Infant CPR (optional)
† Written Exam (optional)
Lead Instructor___________________________________________
Status: † BLS Instr.
† HS Instr.
† BLS TCF/RF
Status Renewal Date: _______________________________________
Training Center____________________________________________
Course Location____________________________________________
* Adult CPR AED, Child CPR AED and Infant CPR
are mandatory for Vanderbilt staff
Course Start Date/Time_______________
Course End Date/Time_________________
Total hours of Instruction __________
# of Cards Issued_________
Student/Manikin Ratio__________
Issue Date of cards________________
Assisting Instructors / Specialty Faculty (Attach copy of instructor card for instructors aligned with other than primary TC)
Name
Instr. card Exp. Date
1.
2.
3.
4.
Name
Instr. card Exp. Date
5.
6.
7.
8.
I verify that this information is accurate and truthful, and that it may be confirmed. This course was taught in accordance with AHA guidelines.
____________________________________________
_______________________________________________
Signature of Lead Instructor
Date
Heartsaver CPR AED 2010, page 1
DATE_________________
FULL NAME
PLEASE PRINT
COURSE Heartsaver CPR AED
Job Title
Department
INSTRUCTOR ________________________________
VUNet ID
Adult
CPR/AED
Child
CPR/AED*
Infant
CPR*
Written
Exam
Card
Issued
Y orN
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* Adult CPR AED, Child CPR AED and Infant CPR are mandatory for Vanderbilt staff
Heartsaver CPR AED 2010, page 2