Course Completion Worksheet

Course Information
Lead Instructor*
Additional Instructors:
Course:*
Other Course:*
Course Location*
Skill Sessions Completed:
- Heartsaver
- BLS
- ACLS
- PALS
Include BLS Add On for ACLS/PALS and CCMC Accelerated/Initial Heartcode BLS as a BLS Skill Session.
Off Site Location:*
Did any participants add on BLS Skills Testing?*
- Yes
- No
Participants are Childcare Providers in Connecticut?*
If yes, please include instruction in the Connecticut Supplemental Materials for Childcare Providers and provide participants with supplemental certificates.
- Yes
- No
Are any Connecticut Children's Medical Center staff?*
Participants are registered for CCMC Acclerated Heartcode BLS or CCMC Initial Heartcode BLS. If they are taking a class independently of the hospital, select "No"
- Yes
- No
Course is provided through the United Way of Connecticut:*
Participants are registered for United Way - Medication Administration for Childcare Providers, United Way - EpiPen Refresher Training, or United Way - Heartsaver Pediatric First Aid CPR AED.
- Yes
- No
Course Date*
Start Time*
: HH
MM
End Time*
: HH
MM
Participant Information
Complete Participants - Heartsaver First Aid CPR AED*
Number of participants that successfully completed the Heartsaver First Aid CPR AED training.
Complete Participants - Heartsaver First Aid ONLY*
Number of participants that successfully completed the Heartsaver First Aid training.
Complete Participants - Heartsaver CPR AED ONLY*
Number of participants that successfully completed the Heartsaver CPR AED training.
Complete Participants - Heartsaver Pediatric First Aid CPR AED*
Number of participants that successfully completed the Heartsaver Pediatric First Aid CPR AED training.
Complete Participants - Heartsaver Pediatric First Aid ONLY*
Number of participants that successfully completed the Heartsaver Pediatric First Aid training.
Complete Participants - Heartsaver Pediatric CPR AED ONLY*
Number of participants that successfully completed the Heartsaver Pediatric CPR AED training.
Complete Participants - BLS Provider*
Number of participants that successfully completed the BLS Provider training.
Complete Participants - ACLS Initial*
Number of participants that successfully completed the ACLS Provider Initial training.
Complete Participants - ACLS Update*
Number of participants that successfully completed the ACLS Provider Update training.
Complete Participants - PALS Provider*
Number of participants that successfully completed the PALS Provider Update training.
Complete Participants - Heartcode BLS*
Number of participants that successfully completed the Heartcode BLS skill session.
Complete Participants - Heartcode ACLS*
Number of participants that successfully completed the Heartcode ACLS skill session.
Complete Participants - Heartcode PALS*
Number of participants that successfully completed the Heartcode PALS skill session.
Complete Participants - Online Heartsaver First Aid CPR AED*
Number of participants that successfully completed the Heartsaver First Aid CPR AED skill session.
Complete Participants - Online Heartsaver First Aid*
Number of participants that successfully completed the Heartsaver First Aid skill session.
Complete Participants - Online Heartsaver CPR AED*
Number of participants that successfully completed the Heartsaver CPR AED skill session.
Complete Participants - Online Heartsaver Pediatric First Aid CPR AED*
Number of participants that successfully completed the Heartsaver Pediatric First Aid CPR AED skill session.
Complete Participants - Medication Administration for Childcare Providers*
Number of participants that successfully completed the Medication Administration for Childcare Providers course.
Complete Participants - Epi Refresher*
Number of participants that successfully completed the Epinephrine Refresher course.
Complete Participants - Advanced ECG/Pharm*
Number of participants that successfully completed the Advanced ECG/Pharm course.
Complete Participants - BLS Instructor*
Number of participants that successfully completed the BLS Instructor course.
Complete Participants - Heartsaver Instructor*
Number of participants that successfully completed the Heartsaver Instructor course.
Participants - Incomplete*
Number of participants that were not successful in completing the training. Specify reason below.
Incomplete Participants:
Please include participant name, reason they were marked incomplete, and what, if any, action needs to be taken by the admin team to follow up.
Participants - No Show*
Number of participants that were on the roster at the start of class but did not attend the training.
Quality Assurance
All Participants Issued Books?*
If an adequate quantity of books were shipped to the client for an off-site class, select "Yes"
- Yes
- No
Book(s) Not Issued:
Include the names of any participants that did not receive a book and the reason why it was not given (i.e. out of stock, refused, etc). Any action required?
All Participants Issued eCards?*
- Yes
- No
eCard(s) Not Issued:*
Include the names of any participants that did not receive an eCard and the reason it was not issued. Admin team will follow up.
All Participants Issued Completion Certificates?*
- Yes
- No
Completion Certificates Not Issued:*
Include the names of any participants that did not receive a Completion Certificate and the reason it was not issued. Admin team will follow up.
All Participants Issued Supplemental Certificates?*
To generate certificates, open the class in Enrollware, click "Certificates" select "Pediatric Supplemental Certificate" and "Generate Certificates"
- Yes
- No
Pediatric Supplemental Certificate(s) Not Issued:*
Include the names of any participants that did not receive a Pediatric Supplemental Certificate and the reason it was not issued. Admin team will follow up.
Paperwork completed, uploaded to Enrollware, and roster finalized?*
- Yes
- No
Heartsaver Instructor: -Instructor Candidate Application -Online Heartsaver Instructor Essentials certificate -Heartsaver First Aid CPR AED skill sheet BLS Instructor: -Instructor Candidate Application -Online BLS Instructor Essentials certificate -BLS Provider written exam -BLS Provider skill test
Enrollware record incomplete:*
Please indicate the reason that the Enrollware record has not been finalized:
Finalized Roster Sent to United Way?*
Finalize the roster in Enrollware, click "View Roster" then click "Email Roster" and in the "To:" field enter "[email protected]"
- Yes
- No
United Way record incomplete:*
Please indicate the reason that the United Way Roster was not sent:
eCards and Finalized Roster Sent to CCMC?*
Have participants print their eCards. Scan them and email them to "[email protected]" Finalize the roster in Enrollware, click "View Roster" then click "Email Roster" and in the "To:" field enter "[email protected]"
- Yes
- No
CCMC eCards/roster incomplete:*
Please indicate the reason that the CCMC eCards/roster record has not been completed:
Evaluations
Please tally the scores for question 3a on student evaluations. Include any comments that are left on evaluations.
Excellent Marks:
Number of participants that checked "Excellent" for evaluation question 3a.
Good Marks:
Number of participants that checked "Good" for evaluation question 3a.
Fair Marks:
Number of participants that checked "Fair" for evaluation question 3a.
Poor Marks:
Number of participants that checked "Poor" for evaluation question 3a.
List any comments participants wrote on their evals:
Opportunities
Ask participants to introduce themselves at the start of class. Note any trends (i.e. half the class were nurses at Hartford Hospital who said there were no classes scheduled at their workplace) or opportunities (participant Little Anne asked for information about purchasing an AED for her office).
List any trends or opportunities identified in this class.
Facilities, Equipment, Inventory
Office was clean and professional upon your arrival:*
- Yes
- No
What was wrong?*
Feel free to text a photo of how you found the office to Mark at 860.786.2816.
Office was clean and professional upon your departure:*
Check trash - if more than half full, please take it out.
- Yes
- No
What is needed?*
One full and sealed box of masks is in stock:*
- Yes
- No
One full and sealed box of first aid kits are in stock:*
- Yes
- No
Count Remaining BLS Provider Books*
A sealed case is 30 books.
Count Remaining ACLS Books:*
Count Remaining PALS Books:*
Count Remaining Heartsaver First Aid CPR AED Books*
Do not include HS PEDIATRIC, HS CPR ONLY, or HS FA ONLY books in this stock.
Count Remaining Heartsaver PEDIATRIC First Aid CPR AED Books*
Most offices don't carry this title, enter 0 for none.
All equipment was clean and in good working order:*
- Yes
- No
What equipment is broken?*
Please indicate what was wrong with any pieces of equipment including the ID number (i.e. Adult Manikin #14, lights won't turn on). Take any unsafe equipment out of service and label it as out of service.
Notes
Is there anything we can do to make Code One better?
How?
Instructor comments/notes:

Course Information

Participant Information

Quality Assurance

Evaluations

Opportunities

Facilities, Equipment, Inventory

Notes

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