INSTRUCTOR MONITOR FORM
Name:
SS#:
Street Address:
City/State/Zip:
Home Phone #:
Work Phone #:
E:MAIL Address:
Employer:
Title:
Date attended Instructor Course:
Lead Instructor of Instructor Course attended:
TC Affiliation:
AHA ECC Discipline Instructor being monitored for:  ACLS
 BLS
 BLS I/T
 PALS
Reason for Monitoring:
 Initial Recognition
 Renewal
Instructor Card Expiration Date:
Attach documentation of courses taught and mandatory updates attended.
 Remediation (for repeat monitoring as needed if previous monitoring is unsuccessful)
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INSTRUCTIONS: This portion to be completed by the Reviewer.
Teaching was monitored during the following part(s) of the course: (Check all that apply.)
 Lecture
 Teaching/Skills Stations
 Evaluations/Skills Stations
 Remediation
(E = Excellent, S = Satisfactory, NI = Needs Improvement) *Comment on all areas marked “NI”.
Check the appropriate box for all areas monitored.
E
S
Teaching Effectiveness
Introduces objectives; Covers core content
following outline; Demonstrates mastery of course
content; Willingness and ability to demonstrate
skills; Manages time effectively; Professionalism
(attire, terminology, etc)
Form O
Revised 11/00
H:\ems\ctc\forms\updated 11-00\Inst Monitor.doc
*NI Comments
Check the appropriate box for all areas monitored.
E
S
*NI Comments
Evaluation Effectiveness
Uses performance checklists; Evaluates fairly;
Provides appropriate remediation
Materials/Equipment
Clean and in good working order; Uses current
AHA materials; All students are using a textbook
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This Instructor Candidate should:
 Be completed
 Be renewed
 Not be completed or renewed (Please explain.)
Comments:
Signature of Reviewer
Date
Mark Reviewer’s Instructor status:  TC Faculty/RF
Mark Reviewer’s Instructor Discipline:  ACLS
 IT
 BLS
 PALS
Monitoring Course Location:

Instructor Candidate’s Comments:
Signature of Instructor Candidate
Form O
Revised 11/00
Date
H:\ems\ctc\forms\updated 11-00\Inst Monitor.doc