NEW! AIO FORM EYES ON HEALTH CPR SERVICES

EYES ON HEALTH CPR SERVICESNATIONAL TRAINING CENTERAMERICAN HEART ASSOCIATION
INSTRUCTOR AFFILIATION AGREEMENT
This agreement is executed between Eyes On Health CPR Services, AHA National Training Center and ________________________________________. The Instructor agrees to follow the administrative policies established by the American Heart Association and administered by EOHCPR. These include:

First NameLast Name
- Providing courses where necessary to meet the training needs
- Submit course notifications to the training center as appropriate (BLS and ACLS)
- Submit course rosters within 20 days of course completion
- Conduct all courses in accordance with AHA Policy
- Utilize appropriate AHA text and instructional materials
- Decontaminate manikins in accordance with manufacturers instructions
- Attend annual updates
- Teach the required minimum number of courses (4 classes over 2 years)
- Be monitored in at least on course annually
Eyes On Health CPR Services will provide administrative services that will include:
- Processing course rosters
- Issuing ecards in a timely manner, 20 day max time frame
- Monitoring of instructor activities and reporting activity to Regional and National Affiliates
- Provide Update information
- Serve as a liaison to the National and Southeast Region of the American Heart Association from EOHCPR Training Center
I do hereby agree to follow the requirements of the American Heart Association and the EOHCPR Training Center,
Instructor Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Please indicate your level(s) of certification:

STOP!

For Training Center Coordinator, go to next page
Verification of Instructor Potential: I verify that this Instructor candidate has achieved a score of 84% or higher on the provider written examination in the discipline for which he or she is applying and has completed at least 1 of the following options:
Signature of Training Center (TC) Faculty/Course Director: (circle appropriate title)
Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate

TC Alignment and Atlas Verification: TC Coordinator of aligning TC has verified the following:
Verification Options
Instructor ID #:
Renewal Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
TC Name:
TC ID #:
Signature of TC Coordinator:
Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate

American Heart Association Emergency Cardiovascular Care ProgramsInstructor/Training Center Faculty Renewal Checklist
Instructions: This checklist may be used to document successful completion of instructor/Training Center Faculty (TCF) renewal requirements and contact information. It is recommended that the TC keep the completed form in the instructor's file.

Complete 1 form per renewing discipline.

To be used in conjunction with the Instructor Monitoring Tool.
SECTION 1:General information for the renewing instructor or TCF member.
Renewing discipline:
Instructor ID#:
Expiration date of instructor card: 6/202
Primary TC name: Eyes On Health CPR Services
TC ID #: GA50566
TC Coordinator's name: Elaine Wiggins
Instructor's or TCF's name:

First NameLast Name
Mailing address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone:
Format: (000) 000-0000.
Email:
example@example.com
SECTION 2:Instructor or TCF member teaching, monitoring, and update activity for renewal.
[X] Instructor/TCF monitoring completed successfully:
Course name: BLS or Heartsaver *circle one
TCF observer name: E. Wiggins/
Monitoring Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Update 1 Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Update 1 Location:
Update 2 Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Update 2 Location:
Update 3 Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Update 3 Location:
Essentials Course Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Essentials Course Location:

Rows	Course Name	Date	Location (TC or Site)	Station or Module
1
2
3
4

Rows	Course Name	Date	Location (TC or Site)	Station or Module
1
2

EYES ON HEALTH CPR SERVICESNATIONAL TRAINING CENTERAMERICAN HEART ASSOCIATION

INSTRUCTOR AFFILIATION AGREEMENT

American Heart Association Emergency Cardiovascular Care ProgramsInstructor Candidate Application

STOP!

TC Alignment and Atlas Verification: TC Coordinator of aligning TC has verified the following:

American Heart Association Emergency Cardiovascular Care ProgramsInstructor/Training Center Faculty Renewal Checklist

SECTION 1:General information for the renewing instructor or TCF member.

SECTION 2:Instructor or TCF member teaching, monitoring, and update activity for renewal.

American Heart Association Emergency Cardiovascular Care ProgramsInstructor/Training Center Faculty Renewal Checklist

SECTION 3:Administrative Review of Conflict of Interest and Code of Conduct. Reviewed by TC Coordinator with instructor.

SECTION 4:Administrative Competencies and Indicators. Observed by TC Coordinator through regular teaching activities

American Heart Association Emergency Cardiovascular Care ProgramsInstructor/Training Center Faculty Renewal Checklist

Program Administration: Successfully manages available resources, including time, materials, space, and budget, to deliver high-quality training in accordance with AHA guidelines