Basic Life Support for Healthcare Providers (BLS-HCP)

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					                                             American Heart Association Emergency Cardiovascular Care Program
                                              Basic Life Support for Healthcare Providers (BLS-HCP)
                                                                     Course Roster Form



        New Course               Renewal Course                                 Lead Instructor:
                                                                                Status: BLS Instr.    BLS TCF/RF
        BLS for Healthcare Provider Course:                                            Status Renewal Date:
     This course must include these HCP Core components:
              Adult/Child CPR and Adult/Child AED                               Training Center: CPR Consultants, Inc.
              Adult/Child/Infant Choking Management                                              7404 Chapel Hill Road, Suite G, Raleigh, NC 27607
              Adult/Child/Infant Mask and Bag-Valve-Mask
              Infant One/Two-Rescuer CPR                                        Site Name:



  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     Module / Station    Name                         Instr. card    Exp. Date    Module / Station
  1.                                                                             5.
  2.                                                                             6.
  3.                                                                             7.
  4.                                                                             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




                                                                                                                 AHA BLS Healthcare Provider Course      Page 1
Date:                        AHA Course: BLS - Healthcare Provider Course Participants      Instructor:

                 NAME                                   Address                          Telephone         Complete/   Remediation/    Exam
      Please PRINT as you wish your                                                                       Incomplete      Date         Score
       name to appear on your card.                                                                                     Completed


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                                                                                                             AHA BLS Healthcare Provider Course   Page 2