EVAC CPR Program AHA Course Roster

EVAC CPR Program AHA Course Roster
Course Information

Heartsaver & BLS classes are 4 hours long. ACLS/PALS classes are 8 hours long. HeartCode classes are 2 hours long.
Class Start Date/Time*

MonthDayYear
Date
Hour MinutesAM/PM Option
Class End Date/Time*

MonthDayYear
Date
Hour MinutesAM/PM Option
Total Hours of Instruction*
Basic Life Support Provider (BLS)Advanced Cardiovascular Life Support Provider (ACLS)Pediatric Advanced Life Support Provider (PALS)Combined BLS, ACLS, & PALSCombined ACLS & PALSCombined BLS & ACLSCombined BLS & PALSHeartsaver CPR/AED/First Aid with Stop the BleedHeartsaver CPR/AEDHeartsaver First Aid with Stop the BleedHeartsaver PediatricStop the BleedOther
Classroom/Instructor-LedHeartCode/Hybrid Learning
Child CPR/AEDInfant CPR
Training Center*
If BLS/Heartsaver, please select EVAC. If ACLS/PALS, please select Upstate NY Life Support
Training Site (if applicable)
Course Location (If Different From TC/TS Location):
Used for courses taught outside of TC/TS
Course Notes
Instructor Information
Lead Instructor Name & ID #*
Please Select Yourself
Lead Instructor E-mail*
example@example.com
Instructor Card Expiration Date*

MonthDayYear
Provider Card Expiration Date*

MonthDayYear
Assisting EVAC Instructor Name & ID # (if applicable)
Please Select An Assisting EVAC Instructor (if applicable)
Additional Assisting EVAC Instructor Name & ID # (if applicable)
Please Select An Assisting EVAC Instructor (if applicable)
Additional Assisting Instructor(s)/Instructors from other TC's (if applicable)
Course Participants

Please include Date of Class, First Name, Last Name, Email, and Telephone (optional). Please click "SAVE" after inputting information.
Student List*
Course Documents
Heartsaver Forms:
- Heartsaver CPR/AED Skills Checklists: https://form.jotform.com/253016322731042
- Heartsaver First Aid Skills Checklists: https://form.jotform.com/253016986715060
- Stop the Bleed Certificate: https://form.jotform.com/250814898834067
- Heartsaver Course Evaluation: https://form.jotform.com/253048754551056
BLS/ACLS/PALS Forms:
- Healthcare Provider Skills Checklists
  - BLS: https://form.jotform.com/253006644460047
  - ACLS: https://form.jotform.com/253016205747049
  - PALS: https://form.jotform.com/253016259326051
- Healthcare Provider Written Examination
  - BLS: https://form.jotform.com/211328231169046
  - ACLS: https://form.jotform.com/243457743239060
  - PALS: https://form.jotform.com/243457406549060
- Healthcare Provider Course Evaluation
  - BLS: https://form.jotform.com/253048861272055
  - ACLS: https://form.jotform.com/253048696042056
  - PALS: https://form.jotform.com/253048424857059
Course Files - if using paper forms, please upload and make sure to click "upload" button after Drag & Drop
Equipment Utilization & Decontamination

I hereby certify that I have properly cleaned and decontaminated the equipment mentioned in this document as deemed true and correct to the best of my knowledge.
LAERDAL BLUE 01LAERDAL BLUE 02AHA RED AED 01AHA RED AED 02AHA RED AED 03AHA RED AED 04Other
CHILD BLS 01CHILD BLS 02Other
BLS QCPR ADULT 01BLS QCPR ADULT 02BLS QCPR ADULT 03BLS QCPR ADULT 04BLS QCPR ADULT 05BLS QCPR ADULT 06BLS QCPR ADULT 07BLS QCPR ADULT 08Other
Laerdal TruMonitor + Instructor iPadDART SIM ALS Drug BoxALS Supplies Bag (Airway + Vascular)Laerdal ACLS Adult ManikinAdult Airway ManikinAdult IV Arm Manikin
BLS QCPR INFANT MANIKINBLS INFANT 01BLS INFANT 02BLS INFANT 03BLS INFANT 04BLS INFANT 05BLS INFANT 06BLS INFANT 07BLS INFANT 08Other
Laerdal TruMonitor + Instructor iPadDART SIM ALS Drug BoxALS Supplies Bag (Airway + Vascular)Laerdal PALS Infant ManikinInfant Airway ManikinInfant IO Leg portion of PALS Manikin
Other Equipment Used and/or Equipment Issues:
Ex: Choking Device, First Aid Equipment, Barrier Devices, Bag-Valve-Masks, etc.
Sani-Cloth WipesLysol Disinfectant WipesOther
Final Submission

I affirm that the information contained herein is truthful and that this course was conducted in accordance with the requirements of the American Heart Association as described in the current AHA discipline-specific instructor manual and program administration manual. All required AHA course materials, videos, and student manuals were used in accordance with AHA policy. My submission below confirms my agreement to the rules and standards of the American Heart Association and the Eastchester Volunteer Ambulance Corps, Inc. CPR Program.
Submitted By:*

First NameLast Name
Lead Instructor Signature*

Clear
eCard Payments

*If you are teaching a class for EVAC, please disregard this section and put the number "0" in the Quantity section.
My Products
prevnext( X )
BLS eCard Payment
$8.00 Quantity



Heartsaver eCard Payment
$22.00 Quantity



ACLS/PALS eCard Payment
$40.00 Quantity



Total

$0.00

Payment Methods

Debit or Credit Card

Choose from one of the PayPal options to make your payment.

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EVAC CPR Program AHA Course Roster

Course Information

Instructor Information

Course Participants

Course Documents

Equipment Utilization & Decontamination

Final Submission

eCard Payments