Course Completion Worksheet

Course Information

Lead Instructor:*

Additional Instructors:

Course Date*

Course:*

Location:*

Off Site Location:*

Hours Worked (for Off Site Differential Calculation):*

Off Site Differential will start 10/1/2019.

Complete Participants – ACLS:*

Complete Participants – BLS Provider:*

Complete Participants – Heartsaver First Aid CPR AED:*

Complete Participants – Heartsaver First Aid ONLY:*

Complete Participants – Heartsaver CPR AED ONLY:*

Complete Participants – Heartsaver Pediatric First Aid CPR AED:*

Complete Participants – PALS:*

Complete Participants – Med Admin:*

Complete Participants – Epi Refresher:*

Complete Participants – BLS Add On:*

Incomplete Participants*

No Show Participants*

Quality Assurance

Reason for incomplete roster:*

Reason for no books:*

Reason for no eCards or certificates:*

As of Nov 5, 2019 we are using AHA Direct Connect to issue eCards. To use this method, you must add the AHA eCard Key to your Enrollware account. For assistance, please email rich@code1web.com

Reason for no supplemental certificates:*

Opportunities

List any trends or opportunities identified in this class:

Examples: Margaret wants to purchase an AED for her office. Daniel wants to take ACLS. There were 5 participants from Memorial Hospital because they no longer offer BLS for employees.

Facilities, Equipment, Inventory:

What was wrong?*

Please take a photo and send to amanda@code1web.com (northeast) or brian@code1web.com (southeast).

Inventory Added

Items added to inventory: Please include name of item, quantity, and last 4 digits of tracking number if it was shipped. Items added to inventory should be included in the overall item count below.

Count remaining BLS Provider books:*

A sealed box contains 30 books.

Count remaining ACLS Provider books:*

Count remaining Heartsaver First Aid CPR AED books:*

Count remaining PALS Provider books:*

What equipment needs attention?

Any equipment that is unsafe must be taken out of service and tagged “Out of Service.” Please report any equipment that requires repair as well.

How can we improve?

Notes: