Instructor/tcf Renewal Checklist Template printable pdf download

American Heart Association Emergency Cardiovascular Care Programs

Instructor/TCF Renewal Checklist

Instructions:

This checklist may be used to document successful completion of instructor/TCF renewal requirements

and contact information. It is recommended that the TC keep the completed form in the instructor's file.

Instructor/TCF Contact Information

Name: _____________________________________ Instructor ID#: ___________________________

Address: ___________________________________________________________________________

Phone: _________________________________ Fax: ______________________________________

Email: _____________________________________________________________________________

Other contact information: _____________________________________________________________

Discipline: 



BLS

ACLS

ACLS EP

PALS

PEARS

Instructor card expiration date: __________________

Primary TC (for discipline seeking renewal):_______________________________________________

Name of TC Coordinator: ____________________________ TC ID#: __________________________

Renewal Checklist

 Provider skills successfully demonstrated

Date: _______________ Method: _________________

 Instructor/TCF update(s) attended

Date(s): ______________________________________

 Instructor/TCF Monitor Form completed successfully

Date: ___________________

 At least 4 provider courses taught in past 2 years or waiver obtained (see below)

 If applicable (for TCF), 1 instructor/instructor renewal course taught in past 2 years (see below)

Teaching Activity

Course Name

Date

Location (TC/Site)

Station/Module

Instructor/Instructor Renewal Course (if renewing TCF)

Additional courses may be attached or listed on the back of this form.

 New instructor card issued

Date: ________________

 TCF status maintained

Date: ________________

Instructor/TCF Renewal Checklist, Revised March 2013

Instructor/tcf Renewal Checklist Template