American Heart Association Emergency Cardiovascular Care Programs
Basic Life Support for Healthcare Providers (BLS HCP)
eLearning Skills Session Roster
Course Information
 BLS HCP Online
 HeartCode® BLS
 BLS Anytime® for HCP
Instructor _______________________________________________
Training Center Learn CPR 4 Life
Training Center ID# CA20091
All paperwork SINGLE-SIDED. Please include:
Training Site Name (if applicable) AmeriMed CPR Training TS 9600019
 Skills tests
Course Location (name) _____________________________________
 Online course certificate
Address __________________________________________________
 Course evaluations
 Evaluation summary
City, State ZIP _____________________________________________
Course Start Date & Time ___________________
Course End Date & Time _____________________
Total Hours of Instruction _________
No. of Cards Issued _________
Student-Manikin Ratio __________
Issue Date of Cards ________________
Assisting Instructors (Attach copy of instructor card for instructors aligned with a TC other than the primary TC)
Name and Instructor ID#
1.
2.
3.
Card Exp. Date
Name and Instructor ID#
Card Exp. Date
4.
5.
6.
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
OFFICE:  Paid / Invoiced ________  Certs issue date _______  Certs issued via ______________
 in Excel  Scanned  Emailed to LLC4L
BLS HCP eLearning Skills Session Roster 2011, page 1
Session Roster for (course) ______________________________
Instructor ______________________________________________
Instructor ID# ___________________________________________
Course Participants (Note: If you are performing multiple skills practice and testing sessions over multiple days, you may use 1 roster.)
Name and Email
Please PRINT as you wish your name to appear
on your card. Please print email address legibly.
Address
Telephone
Session
Date
Session
Start
Time
Session
End
Time
Successfully
Completed
Y or N
Remediation
Date
(if applicable)
1.
2.
3.
4.
5.
6.
7.
8.
9.
BLS HCP eLearning Skills Session Roster 2011, page 2