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, first aid kits, and each student workbook title are in stock:*

Check inventory: Each item should have one sealed full box in stock plus an open box that is being distributed. Select "No" to view the list of all titles you should have.

Yes
No

Inventory*

Which items do NOT have a full, sealed box in stock? Note: Effective 7/1/18 we will be only stocking HS FA CPR textbooks for all Heartsaver courses except HS PEDI. Please use up any remaining HS FA and HS CPR books for participants in these course. Once those books are gone, please issue the combination HS FA CPR book to anyone in Heartsaver courses. We will continue to stock HS PEDI books in HTFD, HVN, and ABE.

ACLS Student Workbook
BLS Student Workbook
Heartsaver First Aid CPR AED Student Workbook
Heartsaver Pediatric First Aid CPR AED Student Workbook
PALS Student Workbook
First Aid Kits
Pocket Masks

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: