ALS Programs Instructor Courses Roster April 2004, page 1
American Heart Association Emergency Cardiovascular Care Program
ACLS and PALS Program Instructor Courses
Course Roster Form
Status: TC Faculty Regional Faculty
ACLS Instructor ACLS EP Instructor
Status Renewal Date: _______________________________________
This course includes all of the ACLS Instructor Course core components.
This course includes all of the PALS Instructor Course core components.
Course Start Date/Time_______________
Course End Date/Time_________________
Total hours of Instruction __________
# of Cards Issued_________
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
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
ALS Programs Instructor Courses Roster April 2004, page 2
DATE_________________ COURSE _____________________________
Please PRINT as you wish your name to
appear on your card.