EVAC CPR Program AHA Course Roster

EVAC CPR Program AHA Course Roster

American Heart Association Emergency Cardiovascular Care Programs
Course Information
Course*

Basic Life Support Provider (BLS)Heartsaver Total CPR/AED/First AidHeartsaver CPR/AEDHeartsaver First AidHeartsaver PediatricAdvanced Cardiovascular Life Support Provider (ACLS)Pediatric Advanced Life Support Provider (PALS)Combined BLS, ACLS, & PALSCombined ACLS & PALSCombined BLS & ACLSCombined BLS & PALSBLS Instructor EssentialsOther
Format*

Classroom/Instructor-LedHeartCode/Hybrid Learning
Heartsaver Optional Modules (please select if completed)

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)
If ACLS/PALS, please select EVAC.
Course Location (If Different From TC/TS Location):
Used for courses taught outside of TC/TS
Course Notes
Start Date/Time*

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

MonthDayYear
Date
Hour MinutesAM/PM Option
Total Hours of Instruction*
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
Lead Instructor Signature*

Clear
Assisting Instructor Name & ID #
Please Select An Assisting EVAC Instructor (if applicable)
Additional Assisting Instructor(s) (if applicable)
Course Participants
Student List*
JotForm Links & Upload Attachments

Please Complete Required JotForms at the links found below or if using paper forms please drag & drop your Course Files such as: Course Evaluations, Skills Sheets, Exam Answer Sheets, and Heartcode Online Certificates
BASIC LIFE SUPPORT FORMS:

AHA Course Roster Submission:

https://form.jotform.com/70095951804156

Basic Life Support: Written Examination:

https://form.jotform.com/211328231169046

Basic Life Support: Adult Skills Testing Checklist:

https://form.jotform.com/210936546397062

Basic Life Support: Infant Skills Testing Checklist:

https://form.jotform.com/211096223084045

American Heart Association Course Evaluation:

https://form.jotform.com/211095867899072

HEARTSAVER FORMS:

AHA Course Roster Submission:

https://form.jotform.com/70095951804156

Heartsaver: Adult Skills Testing Checklist:

https://form.jotform.com/211095448699065

Heartsaver: Child Skills Testing Checklist:

https://form.jotform.com/211096281269054

Heartsaver: Infant Skills Testing Checklist:

https://form.jotform.com/211095801019044

Heartsaver: First Aid Skills Testing:

https://form.jotform.com/211095768395063

American Heart Association Course Evaluation:

https://form.jotform.com/211095867899072

ADVANCED CARDIOVASCULAR LIFE SUPPORT (ACLS) FORMS:

AHA Course Roster:

https://www.jotform.com/70095951804156

ACLS Adult High-Quality BLS Skills Checklist: https://www.jotform.com/242477663847067

ACLS Airway Management Skills Checklist: https://www.jotform.com/242477680757066

ACLS MegaCode Skills Checklist: https://www.jotform.com/242596567970069

ACLS Provider Written Examination: https://form.jotform.com/243457743239060

AHA Course Evaluation: https://www.jotform.com/211095867899072

ACLS Student Guide/Sign-In: https://www.jotform.com/242668065047158

PEDIATRIC ADVANCED LIFE SUPPORT (PALS) FORMS:

AHA Course Roster: https://www.jotform.com/70095951804156

PALS Child CPR/AED Skills Checklist: https://www.jotform.com/242478119120048

PALS Infant CPR Skills Checklist: https://www.jotform.com/242478117426055

PALS Airway Management Skills Checklist: https://www.jotform.com/242596885354068

PALS Rhythm Disturbance/Electrical Therapy Skills Checklist: https://www.jotform.com/242596838673070

PALS Vascular Access Skills Checklist: https://www.jotform.com/242596176598071

PALS Case Scenarios Checklist: https://www.jotform.com/242596244131050

PALS Provider Written Examination: https://form.jotform.com/243457406549060

AHA Course Evaluation: https://www.jotform.com/211095867899072

PALS Student Guide/Sign-In: https://www.jotform.com/242668054412152
Course Files - if using paper forms, please upload and make sure to click "upload" button after Drag & Drop
eCard Payments

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



Heartsaver eCard Payment
$22.00 Quantity



ACLS/PALS eCard Payment
$35.00 Quantity



Total

$0.00
Equipment Utilization & Decontamination
AED Trainers

LAERDAL BLUE 01LAERDAL BLUE 02AHA RED AED 01AHA RED AED 02AHA RED AED 03AHA RED AED 04Other
Child BLS Manikins

CHILD BLS 01CHILD BLS 02Other
Adult BLS Manikins

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
ACLS Equipment

Laerdal TruMonitor + Instructor iPadDART SIM ALS Drug BoxALS Supplies Bag (Airway + Vascular)Laerdal ACLS Adult ManikinAdult Airway ManikinAdult IV Arm Manikin
Infant BLS Manikins

BLS QCPR INFANT MANIKINBLS INFANT 01BLS INFANT 02BLS INFANT 03BLS INFANT 04BLS INFANT 05BLS INFANT 06BLS INFANT 07BLS INFANT 08Other
PALS Equipment

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.
Cleaning Agent

Sani-Cloth WipesLysol Disinfectant WipesOther
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. I understand that a false statement may disqualify my instructor capabilities as well as result in the revocation of my instructor status and affiliation with this Training Center, as well as any other AHA Training Center.

I Agree
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
Should be Empty:

EVAC CPR Program AHA Course Roster

Course Information

Instructor Information

Course Participants

JotForm Links & Upload Attachments

eCard Payments

Equipment Utilization & Decontamination

Final Submission