Wrap Up

Wrap Up

Please complete this at the conclusion of your course.
Access Code
Course Number*
Course Date*

MonthDayYear
Lead Instructor*
Please select name from list that populates. This form routes to Lead Instructor's Branch
Additional Instructors*
Type names of additional instructors (no autofill for this field). Enter "0" if the Lead Instructor is the only instructor.
Type of Course*
AHA Course*
ARC Course*
CBRF Course*
NAEMT & EMS Course*
CPR Skills Taught (Check ALL that apply)*

AdultChildInfant
K-12 or Heartsaver Class*
# of Students Start*
# of Students Complete*
Student(s) who Left or Did Not Pass*
If "Number of Students Start" and "Number of Students Complete" are the same number, enter "0 "
# of Students Initial *
# of Initial Students (a.k.a Recognition, First Time, or New)
# of Students Update*
# of Students Update (a.k.a Renewal; have a current, non-expired card)
# of Rush Certificates ($10 fee per person)*
"Rush" (next business day eCard) entered here has already been paid for. Direct a student who wants to add a "Rush" to call Client Relations.
Additional Notes*
Feedback, Information, Billing Comments
Email Skills Session certificates or other paperwork to your Branch.
APHE TC Equipment Disinfection Verification

All equipment and surfaces will be cleaned and disinfected with a commercial germ-killing disinfectant after each course by the following process:
1. Put on new, clean disposable gloves.
2. As needed, clean any soiled surfaces with a wet paper towel; then, dispose of the paper towl.
3. Apply disinfectant to all surfaces. The surfaces should remain wet for at least six (6) minutes.
4. Wipe any surfaces with clean cloth until dry.
5. Pack up equipment & other supplies.
I complied with the above APHE TC and the AHA or ARC and/or manikin manufacturer guidelines for cleaning and disinfecting the classroom and equipment.*

I agree
Students did not practice “mouth-to-mouth” in this course.*

I agree
Each student had his or her own pocket mask and single-use, disposable mouthpieces.*

I agree
By signing here, I agree that:
- This course was taught in accordance with the appropriate AHA or ARC Guidelines and APHE TC Policies;
- The course equipment was thoroughly and completely disinfected following the above APHE TC Equipment Disinfection Verification.
Signature*

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