BCLS/ACLS REGISTRATION FORM: NEW RESIDENTS
The Hospital requires residents to be certified in Basic Cardiac Life Support (BCLS) and Advanced
Cardiac Life Support (ACLS). The Hospital pays the fees for these courses.
Name: ____________________________________________________________________
Email: ______________________________ Program: ______________________________
BCLS Course: Monday, June 9, 2014.
Please complete the following, attach copies of your BCLS/ACLS cards (if applicable) and return this form
to Graduate Medical Education.
1.
Basic Cardiac Life Support (BCLS):
_____ Yes, I am currently certified in BCLS and have attached a copy of my BCLS card.
_____ No, I am not certified in BCLS and need to attend the BCLS class.
_____ No, I am not currently certified in BCLS, but will be certified prior to my arrival.
forward a copy of my BCLS card.
I will
Class options for BCLS, Monday, June 9, 2014 are below (please rank them). The class will be held
in the Center for Patient Safety & Advanced Medical Simulation (Quarterback Tower, 3rd Floor).
_____ 8:00 a.m. – 10:00 a.m.
_____ 4:00 p.m. – 6:00 p.m.
2.
_____10:30 a.m. – 12:30 p.m.
_____ 6:30 p.m. – 8:30 p.m.
_____1:30 p.m. – 3:30 p.m.
Advanced Cardiac Life Support (ACLS):
_____ Yes, I am currently certified in ACLS and have attached a copy of my
ACLS card.
_____ No, I am not certified in ACLS and need to attend the ACLS class (see below).
_____ No, I am not currently certified in ACLS, but will be certified prior to my
arrival. I will forward a copy of my ACLS card.
ACLS Class Schedule
Tuesday, June 10, 2014 – Class begins at 8 a.m. The Didactic portion will be held in the morning at
Margaret Cameron Spain Auditorium (corner of 19th Street and 7th Avenue South). Practice
Simulations will be held in the afternoon in the Center for Patient Safety & Advanced Medical
Simulation (Quarterback Tower, 3rd Floor). Please rank your preferable time.
_____12:00Noon – 12:45 p.m.
_____3:00 p.m. - 3:45 p.m.
_____1:00 p.m. – 1:45 p.m.
_____ 4:00 p.m. – 4:45 p.m.
____ 2:00 p.m. – 2:45 p.m.
Wednesday, June 11, 2014 – Certification Exam (2 hour test windows) in the Center for Patient Safety
& Advanced Medical Simulation (3rd floor Quarterback Tower)
Test options for ACLS, Wednesday, June 11, 2014 (please rank them):
_____ 8:00 a.m. – 10:00 a.m.
_____ 3:00 p.m. – 5:00 p.m.
____10:00 a.m. – 12:00 p.m
____ 5:00 p.m. – 7:00 p.m.
____ 1:00 p.m. – 3:00 p.m.