Calhoun Community College CTC

Course Information Form

Type of Course:

 Heartsaver CPR Initial  Renewal 

 Adult  Child  Infant

 Heartsaver AED Initial  Renewal 

Including:  AED Training only  Adult CPR

 Child CPR  Infant CPR

 Heartsaver Adult First Aid Initial  Renewal 

Including:  Adult CPR & AED  Environmental Emergencies

 Heartsaver Pediatric First Aid Initial  Renewal 

Including:  Child CPR & AED  Infant CPR  Optional Topics

If teaching Adult & Pediatric First Aid check ALL boxes that apply to the course

 BLS Health Care Provider Initial  Renewal 

 BLS Instructor Initial  Renewal 

 ACLS Provider Initial  Renewal 

 ACLS Instructor Initial  Renewal 

 PALS Provider Initial  Renewal 

 PALS Instructor Initial  Renewal 

CTC Alignment: Calhoun Community College

Course Location:________________________________________________________

Course Director:_________________________________________________________

Lead Instructor:__________________________________________________________

Course Start Date/Time:____________ Course End Date/Time:___________________

Number of Students:______ Number Remediated:______ Number Completed:______

Instructor/Student Ratio:__________ (1:6 optimal)

Student/Manikin Ratio:__________ (3:1 optimal)

Manikins decontaminated by:__________________________(70% Isopropyl Alcohol Recommended)

Medical Director (For ACLS & PALS only):___________________________________

Assisting Instructors: (include position/title for ACLS and PALS classes)

1. ______________________________________________________________

2. ______________________________________________________________

3. ______________________________________________________________

Address and Phone Number of Lead Instructor:

________________________________________________________________________________________________________________________________________________